California Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation practices, the remote California Licensed Clinical Documentation Specialist will provide expert-level review of clinical records, communicate with providers to ensure adherence to evidence-based guidelines, and track productivity for timely reporting.

Key responsibilities

• Reviews clinical documentation within 24-48 hours of admission to ensure alignment with evidence-based guidelines
• Communicates effectively with providers regarding documentation improvement opportunities and educational strategies
• Tracks productivity metrics for accurate reporting and participates in clinical documentation improvement initiatives

Required qualifications

• Undergraduate degree or equivalent experience
• Current RN License or Medical School Graduate
• For RN: 3+ years of acute inpatient CDI experience; for Medical School Graduates: 2+ years of acute inpatient CDI experience
• Experience with ICD-10-CM/PCS documentation requirements and inpatient reimbursement methodologies
• Basic proficiency in Microsoft Word, Excel, and Electronic Medical Records