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 collaborating with cross-functional teams.

Key responsibilities:

• Conduct clinical documentation reviews and rectify identified omissions in medical records
• Integrate processes to enhance the accuracy and completeness of clinical documentation
• Facilitate staff training and education on clinical documentation improvement and coding standards

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
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management, or seven (7) years in a directly related field