Wound Care Clinical Documentation Specialist

Job Summary:
The Clinical Documentation Specialist is responsible for ensuring accurate and complete documentation in patient medical records. This role supports compliance with regulations, enhances the quality of care, and helps optimize reimbursement for healthcare services. The CDS works collaboratively with physicians, coders, and other healthcare staff to clarify clinical information, ensure accurate diagnoses, and assist with appropriate coding and billing.

Key Responsibilities:
Review Medical Records: Conduct thorough reviews of patient medical records for accuracy, completeness, and compliance with regulatory requirements.

Collaborate with Healthcare Providers: Work closely with physicians, nurses, and other clinical staff to clarify documentation in patient charts.

Identify Documentation Gaps: Detect and address inconsistencies or omissions in clinical documentation that could affect patient care or reimbursement.

Educate Providers: Provide education and training to healthcare providers on best practices for accurate documentation and coding requirements.

Assist with Coding: Support coding staff by ensuring that the clinical documentation supports accurate coding and billing for procedures, diagnoses, and treatments.

Comply with Regulations: Ensure that all clinical documentation adheres to applicable healthcare laws, including Medicare, Medicaid, and private-payer guidelines.

Monitor Performance: Track and report on key performance indicators (KPIs) related to clinical documentation, including accuracy rates and reimbursement trends.

Participate in Audits: Assist in internal and external audits by ensuring that medical records meet established standards and guidelines.

Enhance Revenue Cycle: Help optimize the healthcare facility's revenue cycle through accurate documentation, coding, and billing practices.

Qualifications:
Education: Bachelor’s degree in nursing, Health Information Management, or a related field.
Experience: Minimum of 2-4 years of experience in clinical documentation, health information management, or a related area. Experience in coding or billing is preferred.
MUST HAVE WOUNDCARE or PODIATRY EXPERIENCE
Familiarity with LCD's and CMS guidleines is a HUGE PLUS
MUST BE PHYSICIAN/DOCTOR w/ WOUNDCARE EXPERIENCE
Licenses/Certifications: Certified Clinical Documentation Specialist (CCDS), Registered Health Information Administrator (RHIA), or other related certifications are highly desirable.

Skills:
Strong understanding of medical terminology and clinical workflows.
Excellent communication and interpersonal skills.
Knowledge of coding standards (ICD-10, CPT).
Ability to work collaboratively with healthcare professionals.
Strong attention to detail and analytical skills.


Join US Please send your CV to recruitment@thenextlevelva.com