Clinical Documentation Integrity (CDI) Specialist

Clinical Documentation Integrity (CDI) Specialist

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

• 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.

• 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.

• 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.

• 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.

• 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

• 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.

• 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.

• 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!

Caring for Our Team We offer a comprehensive benefits package to support our employees' well-being and professional growth. Benefits include health, dental, and vision insurance available starting the 1st of the month following date of hire, along with life insurance, & short and long-term disability coverage. Paid Time Off begins accruing from day one, and we also provide a 401k plan, an education assistance program, and an employee assistance program. Additionally, employees working evening, night, or weekend shifts may be eligible for a shift differential, adding even more value to your role.

Happy to Help At Meritus, we believe in a collaborative and caring work environment. Interactions are an opportunity to learn, listen and to be there for one another. Therefore, we provide warm welcomes, hospitality-driven closures, and are always Happy to Help.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.