California Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy, the full-time California Licensed Clinical Documentation Specialist will conduct concurrent and retrospective reviews of patient medical records, interact with healthcare teams, and identify improvement opportunities, all while working remotely.

Key responsibilities

• Conduct concurrent and retrospective reviews of patient medical records to ensure documentation accuracy and completeness
• Collaborate with physicians and patient care teams to clarify and gather necessary medical record documentation
• Identify and implement opportunities for improving documentation practices to optimize reimbursement and reporting outcomes

Required qualifications

• Graduate of an accredited school of nursing or foreign-trained physician
• Current RN license in California or foreign-trained physician status
• CCDS or CDIP certification
• Minimum of 5 years of recent relevant experience in clinical documentation
• Strong knowledge of coding classification and reimbursement guidelines