California Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time California Licensed Clinical Documentation Specialist will perform second-level reviews of medical records, provide expert consultation on coding and documentation, and lead staff training initiatives, all while working remotely.

Key responsibilities:

• Conduct second-level reviews of medical records to ensure accuracy and completeness of clinical documentation
• Lead training programs on clinical documentation improvement and collaborate with leadership to identify trends and improvement opportunities
• Facilitate regulatory compliance through audits and by addressing non-compliance issues in line with coding guidelines and federal regulations

Required qualifications:

• Minimum five (5) years of experience in a leadership role related to clinical documentation improvement or integrity
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, along with significant relevant experience
• Proven expertise in clinical documentation, inpatient coding, and quality review processes
• Experience with data analysis and root cause analysis to drive documentation improvement initiatives
• Certification as a Clinical Documentation Specialist or related credential is preferred