California Licensed Clinical Documentation Specialist

Job Summary

To support clinical documentation initiatives, the part-time California Licensed Clinical Documentation Specialist will conduct concurrent and retrospective reviews of medical records, ensuring accurate representation of clinical services and facilitating physician documentation to enhance quality and compliance.

Key responsibilities

• Reviews clinical documentation to improve accuracy in representing severity of illness and complexity of care
• Initiates medical record reviews within 24 to 48 hours of admission and conducts follow-up reviews to ensure compliance with documentation standards
• Partners with clinical providers to address documentation gaps and enhance documentation integrity through queries and educational support

Required qualifications

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