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 practices, 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 and regulatory compliance
• Collaborate with leadership to analyze data and identify trends for enhancing 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 relevant experience
• Minimum twelve (12) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management
• Expertise in medical coding and documentation practices
• Experience with data analysis and root cause analysis in clinical settings