Job Details

Surgery Him Coder

We are seeking a highly detail-oriented and experienced Surgery HIM Coder to join our Health Information Management team. This position is responsible for reviewing, analyzing, and accurately assigning ICD-10-CM, CPT, and HCPCS codes for surgical procedures based on clinical documentation in the patient medical record. The Surgery Coder ensures coding compliance with federal regulations and internal policies to optimize reimbursement and ensure data integrity.

This is a remote position with a 4 day on-site work rotation, every 6-7 weeks.

Essential Job Duties

• Review operative reports, physician documentation, and other clinical records to assign accurate and complete ICD-10-CM, CPT, and HCPCS codes.
• Abstract relevant information from medical records into the health information system.
• Ensure compliance with all coding guidelines (AAPC, AHIMA, CMS, and payer-specific).
• Query physicians when documentation is unclear, conflicting, or incomplete.
• Meet productivity and accuracy standards as established by the department.
• Collaborate with the clinical documentation integrity (CDI) team to support proper documentation practices.
• Stay updated with current coding changes and surgical procedures through continuous education and training.
• Assist in audit processes and respond to coding-related denials as needed.
• Serve as backup to Acute and ED Coding

Qualifications

Required:

• High school diploma or GED.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification from AAPC or AHIMA.
• Minimum of 2 years of surgical coding experience in an acute care or outpatient surgical setting.
• In-depth knowledge of ICD-10-CM, CPT, and HCPCS coding systems.
• Familiarity with EHR systems
• Experience with same-day surgery or ASC coding.

Skills & Competencies

• Strong attention to detail and organizational skills.
• Ability to work independently and meet tight deadlines.
• Excellent written and verbal communication skills.
• Knowledge of medical terminology, anatomy, and physiology.
• Commitment to maintaining confidentiality and data security

Physical Requirements/Working Conditions

• Must be able to sit for long periods
• Must be able to operate standard office equipment
• Must be able to lift and carry up to 20 lbs
• Must be able to work paying close attention to detail with frequent interruptions.
• Ability to work in a fast pace environment.
• Adequate hearing and vision for effective communication.
• Follow complex instructions.
• Think logically in following procedures and instructions.
• Work well under stress, with interruptions and deadlines.
• Effectively communicate dept needs to other departments.