California Licensed Documentation Specialist

Job Summary

Working remotely on a full-time basis, the California Licensed Documentation Specialist will review medical records to ensure accuracy and completeness of clinical documentation, assign medical codes, and support clinical documentation improvement initiatives while driving regulatory compliance.

Key responsibilities

• Conduct clinical documentation reviews and rectify identified omissions in medical records
• Integrate processes to enhance clinical documentation integrity and support documentation improvement initiatives
• Facilitate staff training and education on clinical documentation standards and compliance requirements

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