The Clinical Documentation Specialist (CDS) ensures the accuracy, completeness, and consistency of clinical documentation to support high-quality vascular care, including peripheral arterial disease (PAD), embolization procedures, venous interventions, and wound care services. The CDS collaborates with physicians, advanced practice providers (APPs), revenue cycle teams, coders, and clinical operations to optimize documentation for patient safety, regulatory compliance, and appropriate reimbursement in the outpatient setting.
- Review outpatient vascular procedure and wound care documentation (including PAD revascularization, embolization, vein ablation/sclerotherapy, debridement, skin substitutes, and other wound care interventions) for accuracy, completeness, and consistency.
- Identify gaps or inconsistencies in provider documentation and proactively query clinicians to clarify diagnoses, procedure details, medical necessity, and coding-relevant elements.
- Ensure alignment of documentation with payor requirements, especially for complex procedures involving devices, catheters, IVUS, embolic agents, biologics, and advanced wound care products.
- Ensure medical records clearly demonstrate medical necessity and appropriateness, not solely adherence to Medical Coverage Guidelines (MCGs).
- Collaborate with revenue cycle, pre-authorization and clinical operations to track and report trends in denials and documentation deficiencies across vascular and wound care services; develop targeted education for providers and staff to reduce recurrent issues.
- Collaborate with revenue cycle, pre-authorization, and compliance teams to minimize denial risk and support appeals when necessary.
- Educate providers on documentation best practices through quarterly educational sessions (e.g., PowerPoint presentations), including refreshers for existing providers and onboarding for new staff, with predetermined, rotating topics.
- Collaborate with clinical operation leadership to review payor Medical Coverage Guideline (MCG) updates and coordinate with authorization and health care team to implement required changes.
- Collaborate in EMR documentation builds-including templates, macros, and other tools-to ensure that medical necessity and billing requirements are met for both vascular and wound care services.
- Collaborate with third-party and external auditors, review recommendations, educate providers, and implement documentation and EMR changes as needed.
- Provide ongoing education to providers and clinical staff on diagnosis specificity (e.g., Rutherford class for PAD, wound staging), medical necessity, and procedure details.
- Maintain knowledge of payer policies, regulatory changes, and industry best practices related to outpatient vascular and wound care services and clinical documentation improvement (CDI).
- Support documentation improvement initiatives and process enhancements in partnership with clinical operations leadership.
- Participate in monthly denial review meetings to identify trends, develop solutions, and keep stakeholders informed.
- Demonstrate and promote a work culture committed to UVVC's Core Values: understanding, nurturing, ingenuity, trust, excellence, and diversity.
- Demonstrate behaviors that are consistent with UVVC's Standards of Conduct as outlined in our Employee Handbook.
- Maintain the confidentiality and security of Protected Health Information (PHI) in accordance with UVVC policies, the Health Insurance Portability and Accountability Act (HIPAA), and other applicable laws and regulations. PHI is a top priority of our organization.
Qualifications
- RN, LPN, RHIA, RHIT, CCS, CIRCC, or equivalent clinical or coding credential required.
- Minimum 2 years of experience in clinical documentation, medical coding, or vascular/endovascular and/or wound care procedures preferred.
- Strong understanding of outpatient vascular and wound care interventions, including PAD revascularization, embolization, vein treatments, wound debridement, and related CPT/HCPCS codes.
- Familiarity with payor policies, medical necessity criteria (LCDs/NCDs), and OBL/wound care reimbursement guidelines.
- Excellent communication skills to engage with physicians and multidisciplinary teams.
- Proficient in using electronic health records (EHR) and clinical documentation systems.
- Highly dependable; able to meet reliable attendance and punctuality standards for the role.
- Willingness and flexibility to travel. This role will travel regularly, up to 35% on average.