California Licensed Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the California Licensed Documentation Specialist will review medical records to ensure accurate clinical documentation, manage coding assignments, and enhance documentation integrity through training and compliance support.

Key responsibilities:

• Conduct clinical documentation reviews to promote accuracy and completeness while addressing identified issues
• Integrate processes to improve clinical documentation and support the clinical documentation improvement program
• Facilitate staff training and education on clinical documentation standards and coding requirements

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 of relevant experience without a degree