California Licensed Clinical Documentation Specialist

Job Summary

Providing expert-level review of inpatient clinical records, the full-time California Licensed Clinical Documentation Specialist will identify documentation gaps, communicate with providers for clarification, and lead initiatives for clinical documentation improvement while working remotely.

Key responsibilities

• Conduct expert-level reviews of inpatient clinical records within 24-48 hours of admission to ensure accurate code assignment
• Engage in daily follow-up communications with providers to clarify documentation requirements and improve clinical documentation
• Utilize CDI software to document all clarification activities and provide timely feedback to providers regarding documentation opportunities

Required qualifications

• Must be a Medical Graduate (MD or MBBS) or a Registered Nurse (RN) with an active, unrestricted RN License in the US and 5+ years of acute care hospital experience
• Current CCDS, CDIP, or CCS Certification, or willingness to obtain within 1 year of hire
• 2+ years of experience as a Clinical Documentation Improvement Specialist in an acute care hospital setting
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology
• Ability to work Pacific Time Zone business hours (Monday - Friday) regardless of remote work location