Inpatient Surgical Coder

Healthcare Outcomes Performance Co. (HOPCo)•Phoenix, AZ

About The Position

This role 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 coder will independently code high-acuity inpatient orthopedic spine surgery cases, including cervical, thoracic, and lumbar procedures, revisions, fusions, instrumentation, and neurological-related musculoskeletal procedures. Responsibilities include providing real-time feedback and training to coding staff, applying and validating accurate MS-DRG assignments in compliance with CMS, UHDDS, Official Coding Guidelines, and payer-specific requirements. The role also involves identifying coding trends, documentation gaps, and reimbursement risks, communicating these findings to leadership, and maintaining productivity and quality standards for high-volume and high-complexity workloads. The coder will serve as a resource and mentor to less experienced coders, assist with onboarding and education, participate in policy development, coding guideline interpretation, and regulatory updates, and act as a liaison between coding staff, leadership, and external stakeholders. Support for coding audits, denials management, appeals, and quality improvement activities is also expected.

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.
In-depth knowledge of ICD-10-CM/PCS Official Guidelines, UHDDS, CMS regulations, and payer-specific rules.
Advanced understanding of orthopedic anatomy, surgical techniques, and musculoskeletal disease processes.
Knowledge of compliance, audit methodologies, and revenue cycle impacts related to coding.
Familiarity with quality programs, benchmarking, and performance improvement initiatives.
Strong analytical and critical thinking skills for complex inpatient case resolution.
Effective communication skills when interacting with physicians, CDI, and interdisciplinary departments.
Ability to provide coding education and informal guidance to coding staff.
Exceptional attention to detail and organizational skills.
Ability to lead coding staff in a collaborative and performance-driven environment.
Ability to manage multiple priorities, including coding, auditing, and team support.
Ability to maintain strict confidentiality and compliance standards.
Ability to work independently while influencing team performance.

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.