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
• Lead training and education programs on clinical documentation improvement and coding standards
• Collaborate with leadership to analyze data and identify trends for improving clinical review processes

Required qualifications:

• Minimum five (5) years of experience in a leadership role related to clinical documentation improvement
• Minimum five (5) years of experience in clinical documentation integrity or improvement
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, or equivalent experience
• Experience in inpatient coding, quality review, or case management
• Certification as a Clinical Documentation Specialist or related credential is preferred