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 enhance clinical documentation improvement programs while supporting regulatory compliance through audits and staff training.

Key responsibilities:

• Review and analyze medical/health records to promote documentation accuracy and completeness
• Integrate processes to improve clinical documentation and resolve documentation issues
• Conduct staff training and education on clinical documentation improvement and coding standards

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, 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, or case management, or seven (7) years in a directly related field