California Licensed Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the California Licensed Documentation Specialist will review medical records for accuracy, assign medical codes, enhance clinical documentation integrity programs, and support regulatory compliance through audits and staff training.

Key responsibilities:

• Conduct clinical documentation reviews and rectify identified omissions or contradictions in medical records
• Integrate processes to improve clinical documentation accuracy and completeness while collaborating on documentation improvement initiatives
• Facilitate staff training and education on clinical documentation improvement and compliance with regulatory 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 related field, with four (4) years of relevant experience, or seven (7) years of experience in a directly related field
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire