Advanced Registered Nurse

GBMC Health Partners is looking for a Clinical Documentation Improvement Nurse/Nurse Coder to join our Primary Care group.

The best candidate will be a clinically experienced nurse coder who is EMR savvy, knows HCC and ICD-10 coding, and who is familiar primary care or ambulatory medicine.

Responsibilities

Review patient charts

Identify clinical documentation improvement opportunities

Advise and educate practice physicians and APCs on documentation & coding changes needed to accurately reflect patient acuity and risk levels

Work with EPIC to optimize build and work flows

Presentation, physician communication, and training skills will also be beneficial in this role.

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.

Knowledge, Skills and Abilities

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

Licensures, Certifications

Current Registered Nurse (RN) license in Maryland required.

Certified Clinical Documentation Specialist (CCDS) certification is preferred.

Principal Duties and Responsibilities

Collaborate with coding and clinical teams to enhance the accuracy and completeness of diagnosis coding across GBMC outpatient practices, supporting risk adjustment and reimbursement optimization efforts.

Lead or support pre-visit documentation reviews to identify documentation gaps, coding opportunities, and clinical indicators requiring clarification prior to patient encounters.

Contribute to both the strategic improvement and direct maintenance of patient problem lists in the electronic medical record (EMR), ensuring accuracy, relevance, and alignment with current clinical status, diagnoses, and coding standards.

Physical Requirements

Ability to sit up to 90% of work time

Ability to concentrate and pay close attention to detail when typing and proofing for up to fifty (50%) percent of work time

Ability to travel to multiple locations and cover multiple practices, as needed

Working Conditions

Primarily an ambulatory care setting, interviewing, assessing and educating patients and families, working with interdisciplinary staff up to 70% of time. Remainder of time in office environment.

Conditions of Employment
Maintain current and valid licensure and certifications.

Pay Range
$73,465.95 - $126,056.34

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity
GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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