Surgery Documentation Specialist bei Careers Page

The Surgery Documentation Specialist is responsible for reviewing and processing all letters of support required for gender-affirming surgical procedures, in accordance with WPATH Standards of Care and practice policies. This role ensures that all documentation is complete, compliant, and accurately reflects the clinical requirements necessary to move patients forward in their surgical journey. The Specialist serves as a key liaison between patients, providers, and the surgical team to maintain quality, consistency, and timeliness in the documentation review process.

Primary Job Responsibilities:

• Review incoming letters of support from mental health providers for completeness and compliance with WPATH Standards of Care.
• Verify provider credentials, licensing, and scope of practice to ensure letters meet established requirements.
• Assess documentation for inclusion of necessary clinical elements (e.g., gender dysphoria diagnosis, informed consent, readiness criteria).
• Provide feedback or request revisions from referring providers when letters are incomplete or noncompliant.
• Maintain organized records of reviewed and approved letters in the patient’s medical chart.
• Collaborate with the surgical team, care coordinators, and external providers to streamline the documentation approval process.
• Ensure all approvals are completed within required timeframes to avoid delays in scheduling surgery.
• Safeguard patient confidentiality in accordance with HIPAA and organizational policies.
• Perform other duties as assigned.

Required Experience, Education, and Skills:

• Bachelor’s degree in healthcare administration, psychology, social work, nursing, or related field (preferred).
• Experience in healthcare documentation review or medical records management (preferred).
• Familiarity with WPATH Standards of Care and gender-affirming healthcare strongly preferred.
• Exceptional attention to detail and ability to interpret clinical documentation.
• Strong organizational, communication, and problem-solving skills.
• Commitment to equity, inclusion, and affirming care for transgender and gender-diverse individuals.