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 perform data analyses and identify improvement opportunities in 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
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field
• Minimum nine (9) years of experience in nursing, medicine, CDI, inpatient coding, or a directly related field
• Expertise in performing clinical documentation audits and ensuring compliance with coding guidelines
• Experience in developing and implementing educational programs for clinical documentation