California Licensed Documentation Specialist

Job Summary

Working remotely on a full-time basis, the California Licensed Documentation Specialist will review medical records to ensure the accuracy and completeness of clinical documentation, assign medical codes, and support regulatory compliance through audits and staff training.

Key responsibilities:

• Review and rectify clinical documentation issues in medical records to enhance accuracy and completeness
• Integrate processes for clinical documentation improvement and support the CDI program
• Conduct staff training on clinical documentation standards and collaborate with team members on educational 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 in a directly related field