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 clinical documentation to ensure accuracy and completeness while serving as a resource for complex cases
• Develop and implement training programs on clinical documentation improvement and collaborate with leadership on data analysis to identify improvement opportunities
• Facilitate regulatory compliance by performing audits, addressing non-compliance issues, and mentoring team members on relevant regulations

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 work experience
• Minimum twelve (12) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field
• Experience in conducting audits and ensuring compliance with coding guidelines and federal regulations
• Ability to develop and lead educational programs for staff on clinical documentation standards and practices