California Licensed Documentation Specialist

Job Summary

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

Key responsibilities

• Conduct clinical documentation reviews and rectify identified omissions or contradictions in medical records
• Integrate processes to enhance clinical documentation improvement and resolve documentation issues
• Facilitate staff training on clinical documentation standards and collaborate with team members on improvement 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 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 of four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management