California Licensed Clinical Documentation Specialist

Job Summary

Working part-time in a remote capacity, the California Licensed Clinical Documentation Specialist will conduct concurrent and retrospective reviews of inpatient and outpatient medical records to enhance clinical documentation quality and support accurate coding practices.

Key responsibilities

• Reviews clinical documentation to improve the representation of patient severity, risk of mortality, and complexity of care
• Initiates and monitors medical record reviews to ensure compliance with documentation standards and conducts follow-up reviews
• Partners with clinical providers to address documentation gaps and enhance documentation integrity through effective communication and query processes

Required qualifications

• Bachelor's degree in Nursing, Medicine, Health Information Management, or a related field
• Five years of progressively responsible inpatient clinical experience; 0-2 years of CDI-related work experience preferred
• Experience in ICU/ED and Academic Medical Centers is preferred
• Knowledge of CMS coding guidelines and methodologies, including ICD-10CM/PCS and CPT coding
• Registered Nurse licensure preferred