Documentation Specialist Jobs in Maryland
Documentation Specialist jobs in Maryland are open across Fulton, Rockville, and Salisbury and other Maryland metros, with employers like KBR, Axle, and KBR hiring at every experience level. Find a role that fits below and apply directly.
Find Documentation Specialist JobsOverview
Showing 5 of 6+ Documentation Specialist jobs
Why work at TidalHealth?
Join a triple 'A' rated team where clinical excellence meets a coastal lifestyle. At TidalHealth, you’ll be part of an award-winning network spanning Maryland and Delaware, recognized by the Leapfrog Hospital Safety Guide for our unwavering commitment to patient care. Whether your expertise lies in specialized clinical fields like neurosurgery, academic mentorship through our graduate medical programs, or the critical professional and support roles that keep our network thriving, we provide the tools and tuition assistance you need to excel.
Clinical Documentation Specialist Position Summary
The Clinical Documentation Integrity (CDI) Specialist ensures accurate and complete provider-based clinical documentation at TidalHealth. This position analyzes patients' clinical status, treatment plans, and medical history to identify documentation improvement opportunities. The role involves thorough chart reviews and collaboration with providers, nurses, consultants, and HIM coding staff to ensure proper reimbursement and accurate clinical data. CDI Specialists audit and monitor key quality indicators such as MHAC/PPCs, PSIs, HACs, and mortality reviews. The Specialist works closely with healthcare teams to ensure compliance with coding standards and regulatory requirements. The CDI Specialist also communicates with providers using verbal and electronic queries to clarify or improve documentation in line with AHIMA guidelines. The Specialist utilizes ICD-10 coding guidelines and applies the guidelines during documentation evaluations. The role includes developing tools and education plans to support accurate provider documentation. CDI Specialists help design workflows for documentation improvement and provide training for staff and new employees.
Education
Bachelor’s degree in nursing (BSN) is required, or relevant clinical CDI experience may be considered.
Required License and/or Certifications
- Licensed as a Registered Nurse (RN) in the state of residency
- Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required.
- CCS, RHIT or RHIA is preferred.
Required experience:
- Minimum of one (1) year in inpatient coding and/or CDI experience
- Previous experience utilizing Microsoft Office products and EMR
Preferred Experience
- Experience in an acute care health facility
- Previous medical record coding/documentation auditing experience
- Experience with APR DRG & MS-DRG payment systems
- Experience with ICD10 coding methodology, coding guidelines and Clinical documentation integrity programs
- Previous experience with auditing quality measures – PSIs, HACs, Mortality, and MHAC/PPCs.
- Experience with EPIC and 3m 360/CDI Engage One
Clinical Documentation Specialist Work Schedule
- Primarily Day shift Monday – Friday.
- Hybrid- Remote position
- Evening and weekend work as needed.
Clinical Documentation Specialist Benefits
Benefits: We provide a robust benefits suite for our eligible team members (36+ hours for 12-hour shifts; 37.5+ hours for standard shifts):
- Health: Medical (including HSA), Dental, Vision, & Prescription
- Wealth: Matching 403(b), Healthcare FSAs, & Dependent Care FSAs
- Growth: $5,000 Tuition Assistance & Certification support
- Balance: Generous PTO and Holidays, Onsite Child Care, Pet Insurance
- Income Protection & Leave: Employer-Paid Short-Term Disability, Paid Leave Program, & Long-Term Disability (LTD for FT)
- Life & Security: Employer-paid Life and additional voluntary benefits such as Accident, Critical Care, additional Life, and more
Location: TidalHealth · Health Information Management-TidalHealth Peninsula Regional
Schedule: Full Time, Monday - Friday, 6:00 am to 2:30 pm
Why work at TidalHealth?
Join a triple 'A' rated team where clinical excellence meets a coastal lifestyle. At TidalHealth, you’ll be part of an award-winning network spanning Maryland and Delaware, recognized by the Leapfrog Hospital Safety Guide for our unwavering commitment to patient care. Whether your expertise lies in specialized clinical fields like neurosurgery, academic mentorship through our graduate medical programs, or the critical professional and support roles that keep our network thriving, we provide the tools and tuition assistance you need to excel.
Clinical Documentation Specialist Position Summary
The Clinical Documentation Integrity (CDI) Specialist ensures accurate and complete provider-based clinical documentation at TidalHealth. This position analyzes patients' clinical status, treatment plans, and medical history to identify documentation improvement opportunities. The role involves thorough chart reviews and collaboration with providers, nurses, consultants, and HIM coding staff to ensure proper reimbursement and accurate clinical data. CDI Specialists audit and monitor key quality indicators such as MHAC/PPCs, PSIs, HACs, and mortality reviews. The Specialist works closely with healthcare teams to ensure compliance with coding standards and regulatory requirements. The CDI Specialist also communicates with providers using verbal and electronic queries to clarify or improve documentation in line with AHIMA guidelines. The Specialist utilizes ICD-10 coding guidelines and applies the guidelines during documentation evaluations. The role includes developing tools and education plans to support accurate provider documentation. CDI Specialists help design workflows for documentation improvement and provide training for staff and new employees.
Education
Bachelor’s degree in nursing (BSN) is required, or relevant clinical CDI experience may be considered.
Required License and/or Certifications
- Licensed as a Registered Nurse (RN) in the state of residency
- Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required.
- CCS, RHIT or RHIA is preferred.
Required experience:
- Minimum of one (1) year in inpatient coding and/or CDI experience
- Previous experience utilizing Microsoft Office products and EMR
Preferred Experience
- Experience in an acute care health facility
- Previous medical record coding/documentation auditing experience
- Experience with APR DRG & MS-DRG payment systems
- Experience with ICD10 coding methodology, coding guidelines and Clinical documentation integrity programs
- Previous experience with auditing quality measures – PSIs, HACs, Mortality, and MHAC/PPCs.
- Experience with EPIC and 3m 360/CDI Engage One
Clinical Documentation Specialist Work Schedule
- Primarily Day shift Monday – Friday.
- Hybrid- Remote position
- Evening and weekend work as needed.
Clinical Documentation Specialist Benefits
Benefits: We provide a robust benefits suite for our eligible team members (36+ hours for 12-hour shifts; 37.5+ hours for standard shifts):
- Health: Medical (including HSA), Dental, Vision, & Prescription
- Wealth: Matching 403(b), Healthcare FSAs, & Dependent Care FSAs
- Growth: $5,000 Tuition Assistance & Certification support
- Balance: Generous PTO and Holidays, Onsite Child Care, Pet Insurance
- Income Protection & Leave: Employer-Paid Short-Term Disability, Paid Leave Program, & Long-Term Disability (LTD for FT)
- Life & Security: Employer-paid Life and additional voluntary benefits such as Accident, Critical Care, additional Life, and more
Location: TidalHealth · Health Information Management-TidalHealth Peninsula Regional
Schedule: Full Time, Monday - Friday, 6:00 am to 2:30 pm
See All 6 Documentation Specialist Jobs in Maryland
Find roles in Maryland that match your experience and apply in just a few clicks.
Find Documentation Specialist JobsDocumentation Specialist Jobs by City in Maryland
Where Maryland roles are concentrated, by current openings.
Documentation Specialist Job Market in Maryland
A snapshot from current Maryland openings, updated as new roles post.
Who's Hiring
- KBR3
- Axle1
- Artech1
- TidalHealth1
Top Industries Hiring
- Consulting & Professional Services4
- Aerospace & Defense2
- Healthcare & Medical Services1
What Maryland Employers Look For
The qualifications that appear most often in documentation specialist jobs across Maryland.
- Bachelor's degree in English, communications, technical writing, or a related field
- Proficiency with authoring tools such as MadCap Flare, Adobe RoboHelp, or Confluence
- Experience writing and editing SOPs, user manuals, or technical guides
- Familiarity with document management systems and version control practices
- Strong attention to detail with the ability to translate complex information clearly
- Knowledge of style guides such as Chicago Manual of Style, Microsoft Writing Style Guide, or APA
Documentation Specialist Jobs in Maryland: Frequently Asked Questions
How many documentation specialist jobs are there in Maryland?
There are 6+ documentation specialist openings in Maryland on Migrate Mate as of June 2026, with the most roles in Fulton, Rockville, and Salisbury. New positions post regularly as employers across Maryland hire.
Which Maryland cities have the most documentation specialist jobs?
Fulton, Rockville, and Salisbury have the most documentation specialist openings in Maryland right now, with additional roles spread across smaller metros statewide.
Which companies hire documentation specialists in Maryland?
Employers hiring documentation specialists in Maryland include KBR, Axle, and KBR, based on current listings on Migrate Mate as of June 2026.
Are there remote documentation specialist jobs in Maryland?
Yes. About 17% of documentation specialist openings tied to Maryland are remote or hybrid as of June 2026. The rest are on-site roles based in Maryland metros.
How do I apply for documentation specialist jobs in Maryland?
You can apply to documentation specialist jobs in Maryland directly on Migrate Mate. Search the listings above, find roles that match your experience and preferred Maryland location, then apply to each one that fits.
See All 6 Documentation Specialist Jobs in Maryland
Find roles in Maryland that match your experience and apply in just a few clicks.
Find Documentation Specialist Jobs