California Licensed Documentation Specialist

Job Summary

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

Key responsibilities

• Review a moderate caseload of medical/health records to ensure accurate clinical documentation and assign appropriate medical codes
• 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 to enhance documentation practices

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 directly related field
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire