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, support clinical documentation improvement initiatives, and assist with regulatory compliance through audits and training.

Key responsibilities:

• Review a moderate caseload of medical records to promote documentation accuracy and assign appropriate medical codes
• Integrate processes to enhance clinical documentation integrity and facilitate issue resolution
• Conduct staff training on clinical documentation standards and collaborate on improvement initiatives

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, or equivalent 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 relevant experience