California Licensed Clinical Documentation Specialist

Job Summary

Proactively improving the quality and accuracy of medical record documentation, the full-time California Licensed Clinical Documentation Specialist will conduct comprehensive audits, solicit clarifications from healthcare providers, and educate staff on documentation guidelines while working remotely.

Key responsibilities

• Facilitate the improvement of medical record documentation through auditing and evaluation
• Collect and analyze data to generate reports and make recommendations for documentation practices
• Educate healthcare providers on documentation guidelines and ensure compliance with coding regulations

Required qualifications

• Five or more years of clinical experience as an RN or Physician, with three years in Clinical Documentation Improvement (CDI)
• CDI Credential (CCDS or CDIP) and a Bachelor of Science in Nursing or equivalent medical degree
• Strong clinical knowledge and ability to interpret clinical documentation
• Familiarity with Utilization Review criteria and Joint Commission/CMS requirements
• Ability to work collaboratively with physicians and staff across the health system