California Licensed Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time remote California Licensed Documentation Specialist will review medical records for accuracy, assign medical codes, support regulatory compliance, and conduct staff training on documentation improvement processes.

Key responsibilities

• Review a moderate caseload of medical/health records to ensure accuracy and completeness of clinical documentation
• Integrate processes to improve clinical documentation and support the clinical documentation improvement (CDI) program
• Conduct staff training and education on clinical documentation standards and 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 additional experience in relevant areas
• 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, or case management