California Licensed Clinical Documentation Specialist

Proactively improving the quality and accuracy of medical record documentation, the full-time California Licensed Clinical Documentation Specialist will conduct comprehensive audits, solicit clarifications from healthcare providers, and educate staff on documentation guidelines while working remotely. Key responsibilities Facilitate the improvement of medical record documentation through auditing and evaluation Collect and analyze data to generate reports and make recommendations for documentation practices Educate healthcare providers on documentation guidelines and ensure compliance with coding regulations Required qualifications Five or more years of clinical experience as an RN or Physician, with three years in Clinical Documentation Improvement (CDI) CDI Credential (CCDS or CDIP) and a Bachelor of Science in Nursing or equivalent medical degree Strong clinical knowledge and ability to interpret clinical documentation Familiarity with Utilization Review criteria and Joint Commission/CMS requirements Ability to work collaboratively with physicians and staff across the health system