Senior Coder - Orthopedics

Northwell Health•Garden City, KS

About The Position

Performs coding and abstracting duties to ensure accurate completion of coding for assigned patient records. The role analyzes medical records, selects and reports diagnoses and procedures, assigns discharge disposition, and supports accurate healthcare data and facility payment. It also ensures accurate OASIS item selection and home care diagnoses, identifies documentation gaps that may affect reimbursement risk or quality scores, and recommends corrective actions. The Senior Coder works independently within established guidelines, manages multiple assignments to meet efficiency and turnaround standards, and may provide work guidance to team members. The role uses coding references and regulatory guidance, generates compliant physician queries when documentation is incomplete or conflicting, and supports clinicians in improving documentation practices. The position also requires ongoing education to maintain coding knowledge and awareness of changes in codes, guidelines, and regulations.

Requirements

High school diploma or equivalent.
Three to five years of technical experience.
One of the following certifications is required: CCS, CPC, CCSP, CIC, COC, CCA, RHIA, or RHIT.
AAPC and CPC are listed as required under additional details.
Five or more years of orthopedic coding experience.

Nice To Haves

Experience with Epic EHR.
Experience with AAPC Codify.
Home Care Clinical Specialist - OASIS (HCS-O) or Home Care Clinical Specialist - Diagnosis (HCS-D).

Responsibilities

Analyze and interpret medical records to ensure accurate, complete, and consistent selection of diagnoses and procedures.
Apply knowledge of anatomy and physiology to interpret clinical documentation and identify applicable codes.
Use coding references and resources, including official guidelines, AHA Coding Clinic, CMS materials, and CPT Assistant, to determine appropriate codes and their applicability.
Apply UHDDS definitions and regulatory guidelines to select principal and secondary diagnoses and significant procedures, reflecting acuity, severity of illness, and risk of mortality when applicable.
Code and report diagnoses, present-on-admission indicators, and procedures.
Assign discharge disposition in accordance with CMS rules and regulations.
Make coding determinations and complete reviews independently to avoid workflow delays.
Manage multiple work demands while meeting efficiency and turnaround standards for coding and DRG assignment.
Assign and report data elements required for SPARCS data collection, congenital malformations, and expirations.
Apply outpatient coding conventions and official CPT rules and other mandated outpatient procedure-code-set guidance.
Assign the appropriate discharge physician in the system.
Generate compliant physician queries to clarify incomplete, ambiguous, or conflicting documentation and apply responses to final coding determinations.
Recognize the impact of coding decisions on the revenue cycle.
Assist in educating physicians and other clinicians about documentation practices, specificity, sequencing, and the inclusion of diagnoses or procedures.
Attend required hospital education programs to maintain and enhance coding skills and stay current with coding changes, guidelines, and regulations.
Complete moderately complex assignments, exercise independent judgment, and work with minimal supervision.
Work with the lead to resolve day-to-day technical or procedural challenges.
May provide work guidance to team members to support accurate and timely task completion.
Ensure accurate OASIS item selection and home care diagnosis.
Identify and correct documentation gaps affecting reimbursement risk or quality scores and recommend corrective actions.
Perform related duties as required.