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 lead training initiatives while working remotely.

Key responsibilities:

• Conduct second-level reviews of medical/health records to ensure accuracy and completeness of clinical documentation
• Lead training and education programs on clinical documentation improvement for staff and collaborate with leadership on compliance initiatives
• Perform audits and root cause analyses to identify trends and opportunities for improvement in clinical documentation processes

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 nine (9) years of relevant experience, or twelve (12) years of related experience without a degree
• Experience in clinical documentation improvement or integrity for at least five (5) years
• Certification as a Clinical Documentation Specialist (CCDS) or similar credential is preferred
• Proficiency in using Electronic Medical Record (EMR) systems, such as Epic, is preferred