California Licensed Documentation Specialist

Job Summary

To enhance clinical documentation accuracy and integrity, the full-time California Licensed Documentation Specialist will review medical records, assign medical codes, support regulatory compliance, and conduct staff training, all while working remotely.

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
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management, or seven (7) years of relevant experience without a degree