California Licensed Documentation Specialist

Job Summary

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

Key responsibilities:

• Review a moderate caseload of medical/health records to promote documentation accuracy and completeness
• Integrate processes to enhance clinical documentation improvement and resolve documentation issues
• Conduct staff training on clinical documentation standards and collaborate on educational 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, or related fields, or seven (7) years of relevant experience