California Licensed Clinical Documentation Specialist

Providing expert-level review of inpatient clinical records, the full-time California Licensed Clinical Documentation Specialist will identify documentation gaps, communicate with providers for clarification, and lead initiatives for clinical documentation improvement while working remotely. Key responsibilities Conduct expert-level reviews of inpatient clinical records within 24-48 hours of admission to ensure accurate code assignment Engage in daily follow-up communications with providers to clarify documentation requirements and improve clinical documentation Utilize CDI software to document all clarification activities and provide timely feedback to providers regarding documentation opportunities Required qualifications Must be a Medical Graduate (MD or MBBS) or a Registered Nurse (RN) with an active, unrestricted RN License in the US and 5+ years of acute care hospital experience Current CCDS, CDIP, or CCS Certification, or willingness to obtain within 1 year of hire 2+ years of experience as a Clinical Documentation Improvement Specialist in an acute care hospital setting Advanced proficiency in clinical medicine, pathophysiology, and pharmacology Ability to work Pacific Time Zone business hours (Monday - Friday) regardless of remote work location