Documentation Specialist

Documentation Specialist

Location: Germantown, TN

Reports To: Operations Manager & Chief Medical Officer

Position Type: Full-Time, Non-Exempt

Position Summary

The Vascular & Vein Institute of the South is seeking a detail-oriented and highly organized Documentation Specialist to support the accuracy, quality, and compliance of clinical documentation across the practice. This role plays a critical part in ensuring that medical records reflect complete, cohesive, and compliant information that supports optimal patient care, accurate billing, and regulatory integrity.

The ideal candidate is meticulous, knowledgeable about clinical documentation standards, and comfortable working closely with providers, clinical staff, and administrative leadership.

Key Responsibilities

Clinical Documentation Review

o Review provider clinical notes to ensure cohesion, completeness, and accuracy across the patient's episode of care.

o Check pre-op histories and physicals against operative notes to ensure all diagnoses, findings, interventions, and procedure indications are properly documented.

o Confirm that clinical documentation supports medical necessity and aligns with procedural details.

Quality Assurance & Compliance

o Ensure documentation meets internal standards, regulatory requirements, and payer guidelines.

o Identify discrepancies, missing information, or inconsistent clinical narratives, and collaborate with providers to obtain clarification or corrections.

o Maintain up-to-date knowledge of documentation best practices, CMS requirements, and vascular-specific documentation expectations.

Provider & Staff Support

o Communicate with physicians and clinical staff to clarify documentation elements in a professional, concise manner.

o Provide feedback and education to providers regarding documentation patterns, areas for improvement, and compliance updates.

o Serve as a resource for questions related to documentation quality, workflows, or expectations.

Data Integrity & Record Management

o Assist in maintaining accurate structured and unstructured data within the electronic health record (EHR).

o Help ensure the integrity of diagnosis coding, procedure reporting, and supporting documentation for billing.

o Track and report documentation trends, deficiencies, and improvement opportunities.

Qualifications

Previous experience in medical documentation, clinical documentation improvement (CDI), or a healthcare administrative role preferred.

· Familiarity with vascular and vein-related terminology highly desirable.

· Strong understanding of medical documentation standards, compliance, and chart review processes.

· Demonstrates outstanding attention to detail, strong analytical capabilities, and excellent written and interpersonal communication skills.

· Ability to collaborate effectively with physicians and clinical teams.

· Experience with EHR systems; proficiency in reviewing and interpreting clinical charts.

Why Join Us

At the Vascular & Vein Institute of the South, we are committed to providing exceptional patient care with cutting-edge treatments. As part of our leadership team, you'll play a key role in ensuring operational excellence and patient satisfaction across our growing network of clinics.

Vascular and Vein Institute of the South, PLLC is an Equal Opportunity Employer. We make employment decisions without regard to race, color, religion, sex (including pregnancy, sexual orientation, and gender identity), national origin, age (40+), disability, or genetic information, and in compliance with all applicable federal, state, and local laws. We also prohibit retaliation against individuals who report a concern, file a complaint, or participate in an investigation.

Job Type: Full-time

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Health savings