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, support clinical documentation improvement initiatives, and conduct staff training on documentation standards and compliance.

Key responsibilities:

• Review a moderate caseload of medical records to promote accuracy and completeness of clinical documentation
• Integrate processes to enhance clinical documentation improvement/integrity (CDI) programs and resolve documentation issues
• Conduct staff training and education on clinical documentation standards and regulatory compliance

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 a minimum of 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