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, assist in enhancing clinical documentation improvement programs, and support regulatory compliance through audits and training initiatives.

Key responsibilities

• Conduct clinical documentation reviews and assign medical codes and DRGs for accurate diagnosis capture
• Integrate processes to improve clinical documentation and resolve documentation issues
• Facilitate staff training and education on clinical documentation improvement and compliance regulations

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