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 sessions on clinical documentation improvement and collaborate with leadership to identify trends and implement improvement initiatives
• Facilitate regulatory compliance through audits and by addressing non-compliance issues in line with coding guidelines

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 significant relevant experience
• Expertise in medical coding and documentation practices
• Ability to perform data and root cause analyses to identify improvement opportunities
• Experience in developing and leading training programs for clinical documentation standards