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, support clinical documentation improvement initiatives, and ensure regulatory compliance through audits and staff training.

Key responsibilities:

• Review a moderate caseload of medical/health records to promote accuracy and completeness of clinical documentation
• Integrate processes to enhance clinical documentation improvement and resolve documentation issues
• Conduct staff training 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, 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, case management, or a directly related field
• Experience with clinical documentation improvement programs and regulatory compliance processes