Inpatient Surgical Coder- PRN
About The Position
This PRN position involves reviewing and abstracting clinical documentation from complex inpatient orthopedic and spine surgery records to assign accurate ICD-10-CM, ICD-10-PCS, DRG, POA, and discharge disposition codes. The role requires independently coding high-acuity inpatient orthopedic spine surgery cases, including various procedures and revisions. The coder will also provide real-time feedback and training to coding staff to enhance quality and productivity, apply and validate accurate MS-DRG assignments in compliance with regulations, and identify coding trends, documentation gaps, and reimbursement risks. Responsibilities include maintaining productivity and quality standards for high-volume, complex workloads, serving as a coding resource and mentor, participating in policy development and regulatory updates, acting as a liaison between coding staff and leadership, and supporting coding audits and denials management.
Requirements
- High school diploma or GED required.
- Must hold at least one of the following: RHIA, RHIT, CCS, or CIC.
- Minimum of 4+5+ years of IP facility/hospital coding experience required.
- Minimum of 4-5 years of recent/current experience coding complex inpatient surgical cases required.
- Extensive experience with inpatient coding (ICD-10-PCS and DRG assignment) required.
- Demonstrated expertise in orthopedic surgical coding across multiple subspecialties.
- Advanced to expert level knowledge of ICD-10-CM, ICD-10-PCS, DRG, CPT and HCPCS coding systems.
- Advanced understanding of DRG and APC reimbursement methodologies, ortho anatomy and spine surgical techniques.
- Proven ability to interpret and apply complex coding guidelines and regulatory updates.
- Strong leadership skills with the ability to mentor and develop coding staff.
- Prominent level of accuracy, critical thinking, and attention to detail.
- Proficiency with coding software, EMR systems, and reporting tools.
Nice To Haves
- Associate or Bachelor’s degree in Health Information Management or related field preferred.
- CCS strongly preferred.
- Prior experience in auditing, mentoring, or leading coding teams strongly preferred.
- Experience with denial management, appeals, and payer audits preferred.
Responsibilities
- Reviews and abstracts clinical documentation from complex inpatient orthopedic and spine surgery records to assign accurate ICD-10-CM, ICD-10-PCS, DRG, POA, and discharge disposition codes.
- Independently codes high-acuity inpatient orthopedic spine surgery cases including cervical, thoracic, and lumbar procedures, revisions, fusions, instrumentation, and neurological-related musculoskeletal procedures.
- Provides real-time feedback and training for coding staff to improve coding quality and productivity.
- Applies and validates accurate MS-DRG assignments while ensuring compliance with CMS, UHDDS, Official Coding Guidelines, and payer-specific requirements.
- Identifies coding trends, documentation gaps, and reimbursement risks and communicates findings to leadership.
- Maintains productivity and quality standards while managing high-volume and high-complexity inpatient workloads.
- Serves as a coding resource and mentor to less experienced coders and assists with onboarding and education initiatives.
- Participates in policy development, coding guideline interpretation, and implementation of regulatory updates.
- Acts as a liaison between coding staff, leadership, and external stakeholders.
- Supports coding audits, denials management, appeals, and quality improvement activities as assigned.
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What This Job Offers
Career Level
Mid Level
Education Level
High school or GED
