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 of clinical documentation, assign medical codes, and support the clinical documentation improvement program while aiding in regulatory compliance efforts.

Key responsibilities:

• Conduct clinical documentation reviews and rectify identified omissions or contradictions in medical records
• Integrate processes to enhance the accuracy and completeness of clinical documentation and documentation issue resolution
• Facilitate staff training and education on clinical documentation improvement and coding standards

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 a related field
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management, or a total of seven (7) years in a directly related field