[Hiring] Clinical Documentation Specialist @United Vein & Vascular Centers

Role Description

We are seeking a detail-oriented Clinical Documentation Specialist to ensure the accuracy, completeness, and consistency of clinical documentation that supports excellent patient care, regulatory compliance, and appropriate reimbursement.

• Partner closely with physicians, advanced practice providers, revenue cycle, coders, and clinical operations to strengthen documentation quality across services.

Key Responsibilities

• Review outpatient vascular procedure and wound care documentation for accuracy, completeness, and consistency.
• Identify documentation gaps or inconsistencies and proactively query clinicians to clarify diagnoses, procedure details, medical necessity, and coding-relevant elements.
• Ensure documentation aligns with payor requirements, particularly for complex procedures involving devices, catheters, IVUS, embolic agents, biologics, and advanced wound care products.
• Confirm that medical records clearly demonstrate medical necessity and clinical appropriateness.
• Collaborate with revenue cycle, pre-authorization, and clinical operations teams to track denial and documentation deficiency trends; develop targeted education to reduce recurring issues.
• Partner with revenue cycle, pre-authorization, and compliance teams to minimize denial risk and support appeals.
• Educate providers on documentation best practices through quarterly educational sessions.
• Work with clinical operations leadership to review payor Medical Coverage Guideline (MCG) updates and coordinate implementation of required changes.
• Collaborate on EMR documentation tools to support medical necessity and billing requirements for vascular and wound care services.
• Provide ongoing education to providers and clinical staff on diagnosis specificity, medical necessity, and procedure details.
• Maintain current knowledge of payer policies, regulatory changes, and industry best practices for clinical documentation improvement (CDI).
• Participate in monthly denial review meetings to identify trends, develop solutions, and keep stakeholders informed.
• Demonstrate and promote UVVC’s Core Values: Understanding, Nurturing, Ingenuity, Trust, Excellence, and Diversity.
• Uphold UVVC’s Standards of Conduct and maintain the confidentiality and security of Protected Health Information (PHI) in accordance with HIPAA.

Qualifications

• RN, LPN, RHIA, RHIT, CCS, CIRCC, or equivalent clinical or coding credential required.
• Minimum of 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.
• Proficiency in electronic health records (EHR) and clinical documentation systems.

Benefits

• Competitive compensation
• Comprehensive benefits (medical, dental, vision, and more)
• Generous paid time off / paid holidays
• 401(k) option
• Opportunity to make a meaningful impact

Compensation

$75,000 — $85,000 USD