California Licensed RN Clinical Documentation Specialist

Job Summary

Seeking a full-time remote California Licensed RN Clinical Documentation Integrity Specialist, this position is responsible for clinically based concurrent and retrospective review of inpatient medical records to enhance documentation quality, promote collaboration among medical staff, and ensure accurate reimbursement.

Key responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records to evaluate documentation and utilization of acute care services
• Facilitate communication between clinical reviews, medical record coders, and physicians to improve documentation accuracy
• Analyze patient status and treatment plans to identify gaps in clinical documentation and advocate for appropriate reimbursement

Required qualifications

• Current license as a Registered Nurse in the State of California
• Associate's degree in nursing required; Bachelor's degree preferred
• Minimum of five years of recent clinical experience in an acute care setting
• At least three years of recent experience performing Clinical Documentation Integrity reviews in an inpatient setting
• Current certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required