California Licensed Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time California Licensed Documentation Specialist will review medical records, assign medical codes, and support compliance audits while working remotely.

Key responsibilities:

• Review and promote the accuracy and completeness of clinical documentation across a moderate caseload of medical records
• Integrate processes to improve clinical documentation and support the clinical documentation improvement (CDI) program
• Conduct staff training and education on clinical documentation standards and collaborate with team members on improvement initiatives

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, along 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, case management, or a directly related field, or seven (7) years of relevant experience