California Licensed Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time California Licensed Documentation Specialist will review medical records, assign medical codes, and support compliance with regulations while working remotely.

Key responsibilities:

• Review and analyze medical/health records to ensure accuracy and completeness of clinical documentation
• Integrate processes for clinical documentation improvement and support training initiatives for staff on documentation standards
• Conduct audits and document cases of non-compliance to ensure adherence to federal and state regulations

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