California Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy, the full-time California Licensed Clinical Documentation Specialist will perform expert reviews of inpatient clinical records, communicate with providers for necessary clarifications, and lead initiatives for documentation improvement while working remotely within the U.S.

Key responsibilities

• Conduct expert-level reviews of inpatient clinical records to identify documentation gaps within 24-48 hours of admission
• Engage in daily communication with providers to clarify documentation needs and ensure accurate code assignment
• Provide leadership in improving clinical documentation by articulating recommendations and feedback to providers

Required qualifications

• Must be a Medical Graduate (MD or MBBS) or a Registered Nurse (RN) with an active, unrestricted RN License and 5+ years of acute care hospital experience
• Current CCDS, CDIP, or CCS Certification or willingness to obtain within 1 year of hire
• 2+ years of experience as a Clinical Documentation Improvement Specialist in an acute care hospital setting
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology
• Intermediate proficiency in Microsoft Office and Electronic Medical Records in a Windows environment