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 diagnostics, and lead training initiatives while working remotely.
Key responsibilities:
- Conduct second-level reviews of medical records to ensure accuracy and completeness of clinical documentation
- Collaborate with leadership to analyze data and identify trends for documentation improvement initiatives
- Develop and lead training programs on clinical documentation improvement and regulatory compliance
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 applying medical codes and understanding diagnosis-related groups (DRGs)
- Experience with auditing clinical documentation for regulatory compliance
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