California Licensed Documentation Specialist

Job Summary

Reviewing a moderate caseload of medical records, the full-time California Licensed Documentation Specialist will promote the accuracy and completeness of clinical documentation while supporting regulatory compliance and conducting staff training remotely.

Key responsibilities:

• Conduct clinical documentation reviews to ensure accuracy and completeness, including assigning medical codes and DRGs
• Integrate processes to enhance clinical documentation improvement initiatives and resolve documentation issues
• Facilitate staff training and education on clinical documentation standards and regulatory compliance

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 a related field, with additional experience in relevant areas
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire