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 and conducting staff training.

Key responsibilities

• Review medical and health records to promote accurate clinical documentation and assign appropriate medical codes
• Integrate processes to improve clinical documentation integrity and resolve documentation issues
• Conduct staff training on clinical documentation improvement and collaborate with team members to enhance education programs

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 related experience without a degree