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 lead staff training initiatives while working remotely.

Key responsibilities:

• Perform 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
• Conduct audits and root cause analyses to support regulatory compliance and identify improvement opportunities

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, or case management