California Licensed Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the California Licensed Documentation Specialist will review medical records to ensure accuracy and completeness, assign medical codes, and enhance clinical documentation improvement programs while supporting regulatory compliance and conducting staff training.

Key responsibilities:

• Review medical/health records to promote documentation accuracy and completeness
• Integrate processes to enhance clinical documentation improvement and resolve documentation issues
• Conduct staff training on clinical documentation standards and collaborate on improvement initiatives

Required qualifications:

• Minimum two (2) years of experience in an inpatient acute care or clinical setting
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or related field, with relevant experience
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire