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, assign medical codes, and support clinical documentation improvement initiatives while adhering to regulatory compliance standards.

Key responsibilities

• Conduct clinical documentation reviews and rectify identified omissions or contradictions in medical records
• Integrate processes to enhance clinical documentation integrity and support documentation improvement initiatives
• Facilitate staff training and education on clinical documentation standards and coding 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
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management, or a total of seven (7) years of related experience