California Licensed Documentation Specialist

Job Summary

Reviewing a moderate caseload of medical records, the full-time California Licensed Documentation Specialist will promote the accuracy and completeness of clinical documentation, assign medical codes, and support regulatory compliance while working remotely.

Key responsibilities:

• Conduct clinical documentation reviews to ensure accuracy and resolve discrepancies in medical records
• Integrate processes to enhance clinical documentation improvement and facilitate training for staff on documentation standards
• Drive regulatory compliance by performing audits and documenting non-compliance cases in accordance with federal and state 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
• Minimum four (4) years of experience in nursing, medicine, clinical documentation improvement, inpatient coding, quality review, or case management
• Alternatively, minimum seven (7) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management