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, assist in clinical documentation improvement initiatives, and support regulatory compliance through audits and training.

Key responsibilities

• Review medical records to promote accuracy and completeness of clinical documentation
• Integrate processes to enhance clinical documentation improvement initiatives and resolve documentation issues
• Conduct staff training and education on clinical documentation standards and 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 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 directly related experience