California Licensed Clinical Documentation Specialist

Working remotely in a full-time capacity, the California Licensed Clinical Documentation Specialist will perform second-level reviews of medical records to ensure accuracy and completeness of clinical documentation, provide expert consultation on medical coding, and enhance the clinical documentation improvement program through collaboration and training initiatives. Key responsibilities: Conduct second-level reviews of medical records to promote documentation accuracy and serve as a resource for complex cases Lead training and education programs on clinical documentation improvement and collaborate with leadership to identify and implement improvement initiatives 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 experience Minimum nine (9) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field Expertise in medical coding and clinical documentation standards Experience in conducting data analysis and root cause analysis to identify trends and improvement opportunities