Clinical Documentation Improvement Nurse
GBMC HealthCare
full-time
Posted on:
Location Type: Office
Location: Towson • Maryland • United States
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Salary
💰 $73,465 - $126,056 per year
About the role
- Under limited supervision from the Director of Primary Care and Senior Director of Population Health, the Clinical Documentation Improvement (CDI) Nurse will assist GBMC Health Partners physicians and advanced practicing clinicians to accurately document patient clinical acuity and illness burden to improve risk management efforts.
- The CDI Nurse will review patient records, including ICD-10 diagnoses and Hierarchical Condition Categories (HCC) to identify and act on opportunities for improvement.
- This resource will also educate and work with providers, system leaders, and EPIC staff to maximize documentation accuracy and efficiency.
Requirements
- Education Associate Degree in Nursing (ADN) with relevant experience required. Bachelor of Science (BSN) preferred.
- Experience Minimum of 5 years clinical nursing experience, preferably in outpatient or internal medicine settings.
- Experience in clinical documentation improvement (CDI), coding, or quality initiatives.
- Proven track record of collaborating effectively with physicians, coding teams, and interdisciplinary healthcare professionals.
- Demonstrated experience in providing provider education or training on clinical documentation or quality measures.
- Strong knowledge of clinical documentation best practices and standards for outpatient/internal medicine.
- Strong knowledge of risk adjustment models, including HCC coding and value-based care reimbursement.
- Strong knowledge of chronic disease processes such as CKD, CHF, COPD, diabetes with complications.
- Strong knowledge of ICD-10-CM coding guidelines and query compliance standards.
- Proficiency in conducting focused and efficient chart reviews to identify documentation gaps, clinical indicators, and opportunities for clarification.
- Proficiency in interpreting clinical data (labs, imaging, history, physicals) to support accurate diagnosis capture.
- Proficiency in using EMRs and CDI/coding software tools for documentation review and query submission.
- Communicate effectively and professionally with physicians, coders, and multidisciplinary teams.
- Deliver targeted education based on trends in documentation and provider performance.
- Work independently and prioritize high-impact cases using data-driven decision-making.
- Adapt to evolving outpatient documentation and compliance standards.
Benefits
- Competitive salary and generous paid time off
- Free parking
- Monthly MTA bus pass subsidy-85% paid by GBMC "if applicable"
- Company subsidized onsite fitness and wellness center "if applicable"
- Pre-paid tuition to pursue professional development, additional certifications, and degree programs
- Comprehensive health, dental, and vision coverage
- 401 (a) and 403 (b) retirement savings plan
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentation improvementICD-10 codingHCC codingrisk adjustment modelschronic disease processeschart reviewsclinical data interpretationdocumentation best practicesquality initiativesprovider education
Soft Skills
collaborationcommunicationindependent workprioritizationdata-driven decision-makingprofessionalismadaptabilityeducational deliveryinterdisciplinary teamworkeffective training
Certifications
Associate Degree in Nursing (ADN)Bachelor of Science in Nursing (BSN)