Clinical Documentation Integrity (CDI) Specialist

About the Role

We are seeking a highly skilled Clinical Documentation Integrity (CDI) Specialist to serve as a clinical expert, educator, and trusted resource for providers, nursing staff, patients, families, and interdisciplinary care teams. In this role, you will lead clinical documentation improvement initiatives that enhance documentation accuracy, support quality outcomes, optimize severity of illness (SOI) and risk of mortality (ROM) capture, and ensure regulatory and reimbursement integrity.

The ideal candidate combines strong clinical expertise with exceptional analytical skills and a passion for improving patient outcomes through documentation excellence. You will collaborate closely with physicians, nursing leadership, care management, utilization review, quality teams, and other healthcare professionals to drive continuous improvement across the organization.

Key Responsibilities

Clinical Documentation Integrity & Quality Improvement

• Conduct concurrent and retrospective medical record reviews to ensure documentation accuracy, completeness, and compliance.
• Identify opportunities to improve clinical documentation that accurately reflects patient acuity, severity of illness (SOI), risk of mortality (ROM), and quality outcomes.
• Partner with providers and clinical teams to clarify documentation and support appropriate clinical representation within the EHR.
• Promote documentation practices that support quality reporting, regulatory requirements, and reimbursement integrity.

Program Leadership & Collaboration

• Coordinate, implement, and evaluate CDI and clinical quality initiatives across the organization.
• Serve as a subject matter expert and resource for physicians, nurses, leadership, and interdisciplinary teams.
• Collaborate with clinical and operational leaders to develop strategies that improve documentation performance and patient outcomes.
• Support organizational goals through process improvement and cross-functional partnerships.

Data Analysis & Performance Monitoring

• Collect, analyze, and interpret clinical, quality, and documentation-related data.
• Monitor key performance indicators and identify trends, opportunities, and areas for improvement.
• Develop actionable recommendations based on outcomes and performance metrics.
• Present findings and progress updates to leadership and key stakeholders.

Education & Professional Development

• Design and deliver education programs for providers, nurses, and healthcare professionals regarding documentation best practices.
• Develop targeted action plans and training initiatives based on audit findings and performance data.
• Foster a culture of continuous learning, compliance, and clinical excellence.

Process Improvement

• Utilize Lean and continuous improvement methodologies to enhance workflows, quality, and operational effectiveness.
• Contribute to initiatives focused on improving value, efficiency, patient outcomes, and service excellence.
• Adapt to evolving regulatory requirements, organizational priorities, and healthcare industry trends.

Required Qualifications

Education

• Associate Degree in Nursing or Bachelor's Degree in a healthcare-related field required.
• Bachelor of Science in Nursing (BSN) preferred.
• Master's Degree in a healthcare-related field preferred.

Experience

• Minimum of three (3) years of experience in:
  • Nursing
  • Care Management
  • Utilization Review
  • Quality Improvement
  • Clinical Documentation Improvement
  • Acute Care Hospital Settings
• Broad-based clinical knowledge and strong understanding of healthcare documentation practices required.

Licensure & Certifications

• Current Registered Nurse (RN) license in Maryland, or eligibility through the Nurse Licensure Compact as applicable.
• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Integrity Practitioner) certification preferred upon hire.
• CCDS or CDIP certification required within three (3) years of hire.
• Additional specialty certification preferred.

Preferred Skills & Competencies

• Expertise in clinical documentation integrity, healthcare quality, and regulatory compliance.
• Strong critical thinking, clinical judgment, and problem-solving skills.
• Exceptional verbal and written communication abilities.
• Proven ability to influence and educate physicians and interdisciplinary teams.
• Strong organizational skills with the ability to manage multiple priorities effectively.
• Advanced attention to detail and commitment to accuracy.
• Proficiency with EHR systems, clinical software applications, and Microsoft Office Suite (Excel, Word, PowerPoint).
• Ability to work independently in a fast-paced, dynamic healthcare environment.
• Knowledge of data analysis, performance improvement methodologies, and Lean principles.

Why Join Us?

As a Clinical Documentation Integrity (CDI) Specialist, you'll play a critical role in improving documentation quality, advancing patient care outcomes, strengthening provider engagement, and supporting organizational excellence. This is an opportunity to make a meaningful impact while working alongside dedicated clinical professionals in a collaborative and innovative healthcare environment.

Join us and help shape the future of clinical documentation excellence and quality patient care!