California Licensed Documentation Specialist

Job Summary

Working remotely on a full-time basis, the California Licensed Documentation Specialist will review medical records to ensure accuracy and completeness of clinical documentation, assign medical codes, and support regulatory compliance through audits and training initiatives.

Key responsibilities

• Conduct clinical documentation reviews to promote accuracy and completeness, addressing identified omissions or contradictions
• Integrate processes for clinical documentation improvement and collaborate on documentation initiatives
• Facilitate 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 a related field
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management, or seven (7) years of experience in a directly related field