Senior Coder - Orthopedics

Northwell•Village of Garden City, NY

5d•$66,300 - $108,311

About The Position

Performs coding and abstracting duties to ensure accurate completion of coding for assigned patient records. The role analyzes medical records, selects diagnoses and procedures, applies applicable coding rules and guidelines, assigns discharge information, and supports accurate healthcare data and facility payment. For home care, the role 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 under minimal supervision, manages multiple assignments to meet efficiency and turnaround standards, and may provide work guidance to team members. The role also generates compliant physician queries, supports clinician education on documentation practices, participates in required education programs, and works with a lead to resolve day-to-day technical or procedural challenges.

Requirements

High school diploma or equivalent.
3–5 years of technical experience.
One of the following certifications or credentials: CCS, CPC, CCSP, CIC, COC, CCA, RHIA, or RHIT.
AAPC and CPC certification, required.
5+ years of orthopedic coding experience, required.
Home Care Clinical Specialist – OASIS (HCS-O) or Home Care Clinical Specialist – Diagnosis (HCS-D).

Nice To Haves

Experience with Epic EHR.
Experience with AAPC Codify.

Responsibilities

Analyze and interpret the full medical record to select accurate, complete, and consistent diagnoses and procedures.
Apply knowledge of anatomy and physiology to interpret clinical documentation and identify applicable codes.
Use coding resources and references, including Official Coding Guidelines, AHA Coding Clinic, CMS resources, and CPT Assistant.
Apply UHDDS definitions and other regulatory guidance to select principal and secondary diagnoses and significant procedures, reflecting acuity, severity of illness, and risk of mortality when applicable.
Code and report diagnoses with associated Present on Admission indicators and procedures.
Assign discharge disposition in accordance with CMS rules and regulations.
Make coding determinations and complete reviews independently to prevent workflow delays.
Manage multiple work demands and meet efficiency and turnaround standards for coding and DRG assignment.
Assign and report data elements required for SPARCS collection, Congenital Malformations, and Expirations.
For outpatient encounters, apply CPT conventions, official coding guidelines, and other applicable rules for mandated outpatient procedure code sets.
Assign the appropriate discharge physician in the system.
Generate compliant physician queries to clarify incomplete, ambiguous, or conflicting documentation and apply query responses to final coding determinations.
Recognize the impact of coding decisions on the revenue cycle.
Assist with educating physicians and other clinicians on documentation practices, specificity, resequencing, and inclusion of diagnoses or procedures when needed.
Attend and participate in required hospital education programs to maintain and enhance coding skills and stay current with coding and regulatory changes.
Complete moderately complex assignments, recognizing when it may be necessary to deviate from accepted practices.
Exercise independent judgment on basic or moderately complex job-related issues.
Work independently within established guidelines and procedures, receiving instruction on new assignments as needed.
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.
Perform related duties as required.
Ensure accurate OASIS item selection and home care diagnosis.
Identify and correct documentation gaps that affect reimbursement risk or quality scores and recommend corrective actions.