California Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time California Licensed Clinical Documentation Specialist will conduct second-level reviews of medical records, provide expert consultation on coding and documentation, and lead staff training initiatives while working remotely.

Key responsibilities:

• Conduct second-level reviews of medical records to ensure accuracy and completeness of clinical documentation
• Lead training programs on clinical documentation improvement and collaborate with leadership to identify trends and improvement opportunities
• Facilitate regulatory compliance through audits and addressing cases of non-compliance 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, or equivalent experience
• Minimum nine (9) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field
• Experience with clinical documentation audits and compliance management
• Strong understanding of medical coding and health care quality standards