California Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation quality, the full-time Associate Clinical Documentation Improvement Specialist will conduct expert-level reviews of inpatient clinical records, communicate with providers for necessary documentation clarifications, and provide leadership for overall improvement in documentation practices while working remotely from anywhere within the U.S.

Key responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit to identify documentation gaps for accurate code assignment
• Conducts daily follow-up communication with providers to obtain needed documentation specificity and clarify information
• Engages with Physician Advisors and HIM Coding Professionals to resolve documentation issues and improve clinical documentation processes

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
• Ability to work Pacific Time Zone business hours (Monday - Friday) regardless of remote work base location