Documentation Specialist

REQUIRED CRITERIA TO APPLY:

• Must currently be employed in the Revenue Cycle Department.
• Must have a minimum of 10 years of progressive experience in revenue cycle processes and procedures.
• Strong knowledge of revenue cycle operations, including patient access, billing, coding, accounts receivable, and collections.
• Excellent communication skills, both written and verbal, with the ability to interact effectively with Ownership, physicians, therapists, and other clinicians.
• Strong problem-solving and critical-thinking skills, with a track record of process optimization.
• Ability to adapt to changing healthcare regulations and implement best practices across the department.

OVERVIEW: 

At Lymphedema Therapy Specialists, Inc. (LTS), we believe our work is more than just a job, it’s a calling. Our mission is rooted in a deep commitment to serve our patients and one another with compassion, integrity, and excellence. Everything we do is guided by faith, love, and unity — values that shape our culture and define how we care for others.

We are a team driven by generosity offering our time, talents, and resources wholeheartedly to meet the needs of our patients and community. Excellence matters to us, not only in our clinical care but in every interaction and task, big or small. We listen with empathy, communicate with kindness, and strive to heal lives physically, emotionally, and spiritually.

At LTS, every individual is seen, valued, and empowered. We believe in investing in our people, encouraging both personal and professional growth as each team member steps more fully into their God-given purpose. We honor the unique contributions of our staff, recognizing their work as a blessing to those we serve.

Joining LTS means becoming part of a mission-driven team united by faith and purpose. If you’re seeking a role where your work has meaning and your gifts can truly make a difference, you’ll find a home here. Welcome to a place where healing happens for our patients, our team, and our community.

We encourage you to visit our website at https://lymphedemateam.com before applying to learn more about our company, culture, and mission. 

JOB SUMMARY:

At Lymphedema Therapy Specialists, Inc. (LTS), the Documentation Specialist plays an essential and mission-aligned role in supporting our commitment to serve patients and one another with excellence, compassion, and integrity. This position is critical to the accuracy and completeness of patient records, helping ensure that our care remains high-quality, compliant, and centered around the needs of those we serve.

The Documentation Specialist focuses on improving the clarity, accuracy, and integrity of clinical documentation within our EHR/EMR systems. Through careful review and collaboration with providers, this role ensures that documentation fully reflects the scope and quality of care delivered. It requires a keen eye for detail, strong clinical knowledge, and a commitment to upholding regulatory standards while honoring the patient story. Above all, the Documentation Specialist must embody a servant mindset — someone who reflects our core values of love, unity, generosity, and excellence in every interaction.

In addition to daily chart review and provider communication, this position involves identifying trends in documentation gaps, offering education to clinical staff, and supporting initiatives that promote complete, accurate, and timely medical recordkeeping. The Documentation Specialist works closely with therapists, administrative staff, and compliance leadership to elevate care documentation practices and ensure alignment with internal goals and external requirements.

The ideal candidate will bring a strong understanding of clinical terminology, coding practices, and healthcare compliance standards, along with excellent communication skills and a heart for supporting others. If you’re passionate about using your expertise to enhance patient care through exceptional documentation, this position offers a meaningful opportunity to contribute to a mission-driven team that brings hope and healing to every patient we serve. 

JOB DUTIES AND RESPONSIBILITIES:

• Evaluate medical records for completeness, accuracy, and consistency to ensure documentation reflects the severity of illness, clinical status, and services provided.
• Communicate with physicians, therapists, and other clinicians to clarify documentation and ensure proper reflection of diagnoses, procedures, and treatment plans.
• Maintain up-to-date knowledge of ICD-10, CPT, and other coding guidelines, as well as regulatory standards (e.g., Medicare, Medicaid, and commercial payer requirements).
• Identify trends and opportunities for improvement in clinical documentation and support education efforts to help providers understand documentation requirements.
• Ensure documentation supports the medical necessity and level of services billed, reducing claim denials and enhancing reimbursement outcomes.
• Navigate and work within electronic health record systems to audit, query, and update clinical documentation as appropriate.
• Generate and communicate clear, compliant, and respectful queries to providers to obtain missing or unclear clinical information.
• Attend case reviews, compliance meetings, or team huddles to provide insights into documentation trends and collaborate on quality improvement.
• Track and report documentation improvement efforts, including query response rates, documentation accuracy, and trends in coding or billing issues.
• Handle all patient information in accordance with HIPAA and organizational privacy policies, maintaining professionalism in all interactions.
• Demonstrate alignment with the spiritual mission of LTS by modeling compassion, service, humility, and excellence in every interaction.
• Execute various tasks, as assigned by your manager, supervisor, or company officer, whether within your standard duties or as requested beyond regular responsibilities.

QUALIFICATIONS:

Education & Licensure:

• High School Diploma or equivalent.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) a plus.

Work Experience:

• Minimum of 10 years of experience in clinical documentation improvement (CDI), medical coding, utilization, or similar role within a healthcare environment strongly preferred.
• Proficient in Electronic Health Records (EHR) and Practice Management systems, with the ability to navigate platforms efficiently and accurately; prior experience with AdvancedMD is highly desirable.
• Skilled in insurance verification and processing referral and authorization requests in alignment with payer requirements.
• Thorough understanding of insurance benefits and the medical billing process, including claims submission, denials, and patient financial responsibility.

Skills:

• Strong verbal and written communication skills with the ability to interact effectively with providers, insurance companies, and healthcare team members.
• Proven ability to multitask, prioritize responsibilities, and remain organized in a fast-paced clinical environment.
• Solid understanding of HIPAA regulations and commitment to maintaining patient confidentiality.
• Strong understanding of medical terminology, anatomy and physiology, and disease processes.
• Familiarity with healthcare regulations, payer requirements, and documentation standards.
• Detail-oriented with strong analytical, critical thinking, and organizational skills.
• Ability to work independently while also collaborating effectively with interdisciplinary teams.
• Skilled in time management and prioritization in a fast-paced clinical setting.
• Alignment with the mission, vision, and core values of LTS, including integrity, service, and excellence.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer (typically 6–8 hours per day).
• Frequent use of hands and fingers for data entry, typing, and handling paperwork.
• Visual acuity required to read and interpret printed and electronic documents, insurance forms, and billing codes.
• Hearing ability to effectively communicate via phone and in person with patients, team members, and insurance representatives.
• Occasional reaching, bending, or lifting of lightweight office supplies, files, or equipment (typically up to 10–15 lbs).
• Manual dexterity to operate office equipment such as computers, printers, copiers, phones, and calculators.
• Ability to maintain focus and attention to detail for extended periods, especially when reviewing patient, financial, and billing records.
• Mobility to move around the office to retrieve files, interact with coworkers, or attend meetings.

Tools and Equipment Used:

Technology & Administrative Tools:

•     Electronic Health Record (EHR) systems (e.g., AdvancedMD)

•     Practice Management Systems (PMS) for billing and scheduling

•     Insurance Payer Portals for claim submissions, verifications, and appeals

•     Clearinghouse platforms (e.g., Availity, Waystar) for claim submissions and remittance tracking 

•     Desktop and laptop computers, tablets

•     Office equipment: printers, phones, fax, scanners

Position Classification:

• This is a salaried, exempt position and is not eligible for overtime pay.
• Compensation is competitive and commensurate with experience, credentials, and qualifications.
• Additional benefits may include paid time off, health insurance, professional development support, and other offerings consistent with company policy.

Benefits:

• Competitive salary
• Health, dental, and vision insurance
• 401(k) with company match
• Paid time off (vacation, sick leave, and holidays)
• Professional development and training support
• Employee assistance program (EAP)
• Weekly team lunches and company-sponsored events

Lymphedema Therapy Specialists, Inc. is an equal opportunity employer and complies with all applicable federal, state, and local laws. This includes, but is not limited to, compliance with the Americans with Disabilities Act (ADA), ADA Amendments Act (ADAAA), Fair Labor Standards Act (FLSA), and Title VII of the Civil Rights Act of 1964. We are committed to creating a respectful, inclusive, and safe work environment for all employees.