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 staff 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 improving clinical documentation processes
• 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 with nine (9) years of relevant experience, or twelve (12) years of experience in a related field
• Experience in clinical documentation improvement or integrity for a minimum of five (5) years
• Certification as a Clinical Documentation Specialist (CCDS) or equivalent credential preferred
• Experience using Epic System software or other Electronic Medical Record (EMR) systems is preferred