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 regulatory compliance while enhancing clinical documentation improvement initiatives.

Key responsibilities

• Review a moderate caseload of medical records to promote accuracy and completeness of clinical documentation
• Integrate processes to improve clinical documentation and support documentation issue resolution
• Conduct 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 related field with relevant experience, or seven (7) years of experience in a related field
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire