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 lead training initiatives, all while working remotely.

Key responsibilities:

• Conduct second-level reviews of medical/health 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 for staff and medical providers

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 related field, along with relevant experience
• Minimum five (5) years of experience in clinical documentation improvement, inpatient coding, or related fields
• Experience with data analysis and root cause analysis methodologies
• Certification in clinical documentation or coding is preferred (e.g., CCDS, CDIP, CCS)