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 enhance the clinical documentation improvement program while supporting regulatory compliance and conducting staff training.

Key responsibilities:

• Review medical/health records to promote accuracy and completeness, and assign medical codes and DRGs
• Integrate processes to improve clinical documentation and resolve documentation issues
• Conduct staff training on clinical documentation improvement and collaborate on education initiatives

Required qualifications:

• Minimum two 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, and four years of relevant experience, or seven years of relevant experience without a degree
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire