California Licensed Documentation Specialist

Job Summary

Working remotely on a full-time basis, the California Licensed Documentation Specialist will review medical records to ensure accuracy and completeness, assign medical codes, and enhance clinical documentation improvement programs while supporting regulatory compliance and conducting staff training.

Key responsibilities:

• Review a moderate caseload of medical/health records to promote accuracy and completeness of clinical documentation
• Integrate processes to improve clinical documentation and support documentation issue resolution
• Conduct staff training and education on clinical documentation improvement and compliance with 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 AND minimum four (4) years of relevant experience, or minimum seven (7) years of relevant experience without a degree