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 support clinical documentation improvement initiatives while collaborating with cross-functional teams.

Key responsibilities:

• Conduct clinical documentation reviews and rectify identified omissions or contradictions in medical records
• Integrate processes to enhance the accuracy and completeness of clinical documentation and support documentation issue resolution
• Facilitate staff training and education on clinical documentation improvement and compliance with regulatory 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 a related field, along with relevant experience
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire