Certified Surgery/Observation Coder
About The Position
The Certified Surgery/Observation Coder reviews provider documentation and revises or assigns ICD-10-CM and CPT/HCPCS codes in accordance with official coding guidelines. The role researches coding and claim edits and takes appropriate action to resolve them. Coding focuses on complex outpatient hospital services, including Observation, Emergency Department, Wound, and Ambulatory Surgery, or provider-based complex procedural services, including surgery, procedures, and wound care. The position requires adherence to coding policies and procedures, use of encoding software and reference materials, communication with providers when additional information is needed, and maintenance of coding quality and productivity standards. The coder also identifies issues that may affect quality, compliance, or productivity and contributes to departmental performance improvement and meetings.
Requirements
- High school diploma required.
- For hospital-based coding: RHIA, RHIT, or CCS certification required; no experience specified.
- For provider-based coding: RHIA, RHIT, CCS, CCS-P, CCA, or CPC certification required.
- For provider-based coders holding CCS-P, CCA, or CPC: three years of procedural coding experience required.
- Intermittent hand manipulation.
- Intermittent lifting and carrying of 20 pounds.
Nice To Haves
- Associate or bachelor's degree in Health Information or a healthcare-related discipline.
Responsibilities
- Follow all coding policies, procedures, and standard operating procedures.
- Use encoding software and reference materials effectively to assign appropriate codes.
- For provider-driven coding, review and accept or revise code selections based on documentation and coding guidelines.
- For non-provider-driven coding, review provider documentation and assign codes based on coding guidelines.
- Review coding edits and resolve them accurately so encounters can be sent to claims.
- Send clear, respectful communications to provider inboxes or queries when additional information is needed before coding is finalized.
- Communicate documentation, coding, or system issues that may affect quality, compliance, or productivity to the Coding Lead, Supervisor, or Manager.
- Perform work queue duties as assigned by the Coding Lead, Supervisor, or Manager.
- Maintain coding quality and productivity standards.
- Participate meaningfully in performance improvement initiatives, department meetings, and other required meetings.
- Maintain required continuing education units (CEUs).
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
