California Licensed Clinical Documentation Specialist

To enhance clinical documentation integrity, the full-time California Licensed Clinical Documentation Specialist will perform second-level reviews of medical records, provide expert consultation on coding and diagnostics, and lead training initiatives while working remotely. Key Responsibilities Conduct second-level reviews of clinical documentation to ensure accuracy and completeness while serving as a resource for complex cases Develop and implement training programs on clinical documentation improvement and collaborate with leadership on data analysis to identify improvement opportunities Facilitate regulatory compliance by performing audits, addressing non-compliance issues, and mentoring team members on relevant regulations Required Qualifications Minimum five (5) years of experience in a leadership role related to clinical documentation improvement or integrity Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, along with relevant work experience Minimum twelve (12) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field Experience in conducting audits and ensuring compliance with coding guidelines and federal regulations Ability to develop and lead educational programs for staff on clinical documentation standards and practices