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 and education programs on clinical documentation improvement and coding standards
- Collaborate with leadership to analyze data and identify trends for documentation improvement initiatives
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
- Minimum nine (9) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management
- Expertise in clinical documentation audits and compliance management
- Experience with Electronic Medical Record (EMR) systems, preferably Epic System software
Complete Job Description
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