Clinical Documentation Specialist
New
U
United Vein & Vascular CentersVascular care
Remote (U.S. Residents Only)Full-TimeJunior
Salary$75,000 — $85,000 USD
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Job Details
- Experience
- Minimum of 2 years of experience in clinical documentation, medical coding, or vascular/endovascular and/or wound care procedures preferred
- Required Skills
- EHRHIPAA
Requirements
- Hold an RN, LPN, RHIA, RHIT, CCS, CIRCC, or equivalent clinical or coding credential.
- Have a minimum of 2 years of experience in clinical documentation, medical coding, or vascular/endovascular and/or wound care procedures; this experience is preferred.
- Understand outpatient vascular and wound care interventions, including PAD revascularization, embolization, vein treatments, and wound debridement.
- Understand related CPT/HCPCS codes.
- Be familiar with payor policies and medical necessity criteria, including LCDs/NCDs.
- Be familiar with OBL and wound care reimbursement guidelines.
- Be proficient in electronic health records and clinical documentation systems.
Responsibilities
- Review outpatient vascular procedure and wound care documentation for accuracy, completeness, and consistency.
- Identify documentation gaps and query clinicians to clarify diagnoses, procedure details, medical necessity, and coding-relevant elements.
- Check documentation against payor requirements for complex procedures and wound care products.
- Confirm medical records demonstrate medical necessity and clinical appropriateness.
- Track denial and documentation deficiency trends with revenue cycle, pre-authorization, and clinical operations teams.
- Educate providers and clinical staff on documentation best practices, diagnosis specificity, medical necessity, and procedure details.
- Review payor Medical Coverage Guideline updates with clinical operations leadership and coordinate required changes.
- Collaborate on EMR templates, macros, and related builds for medical necessity and billing requirements.
- Participate in monthly denial review meetings and help develop solutions.
- Maintain the confidentiality and security of Protected Health Information in accordance with HIPAA.
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