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 support clinical documentation improvement initiatives while ensuring regulatory compliance.

Key responsibilities:

• Conduct clinical documentation reviews and collaborate with team members to rectify omissions in medical records
• Integrate processes to enhance clinical documentation integrity and identify areas for improvement
• Facilitate staff training and education on clinical documentation standards and coding 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 with relevant 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, quality review, or case management