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, 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 improving clinical documentation processes
- Develop and lead training sessions on clinical documentation improvement and compliance with regulatory standards
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 nine (9) years of relevant experience
- Minimum twelve (12) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field
- Experience with audits and compliance management in healthcare settings
- Proficiency in using Electronic Medical Record (EMR) systems, such as Epic
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