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 practices, and lead training initiatives, all while working remotely.

Key responsibilities:

• Conduct second-level reviews of medical records to ensure accuracy and completeness of clinical documentation
• Collaborate with leadership to identify trends and implement improvement initiatives 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 or integrity
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, along with nine (9) years of relevant experience
• Minimum twelve (12) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field
• Experience in conducting audits and ensuring compliance with coding guidelines and federal regulations
• Proven ability to mentor and train staff on clinical documentation standards and practices