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 regulatory standards while working remotely.

Key responsibilities:

• Review and ensure the accuracy and completeness of clinical documentation in medical records
• Integrate processes to improve clinical documentation and support the CDI program
• Conduct staff training on clinical documentation improvement and regulatory compliance

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, 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, or seven (7) years of related experience