California Licensed Documentation Specialist

Job Summary

Promoting the accuracy and completeness of clinical documentation, the full-time California Licensed Documentation Specialist will review medical records, assign medical codes, assist in clinical documentation improvement initiatives, and support regulatory compliance, all while working remotely.

Key responsibilities

• Conduct reviews of medical/health records to ensure accuracy and completeness, and assign medical codes and DRGs
• Enhance clinical documentation integrity by integrating processes and collaborating on documentation improvement initiatives
• Provide 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 a related field, or equivalent 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 in a directly related field