California Licensed Documentation Specialist

Job Summary

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

Key responsibilities:

• Conduct clinical documentation reviews and rectify identified omissions in medical records
• Integrate processes to improve clinical documentation and support documentation issue resolution
• 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 a related field
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field, or a minimum of seven (7) years of relevant experience