Surgical Coder

Job Title: Surgical Coder

Department: Revenue Cycle Management

Reports To: Director of Surgical RCM

Location: Remote

Position Summary:

The Surgical Coder is responsible for accurately reviewing, analyzing, and assigning the appropriate CPT, ICD-10-CM, and HCPCS codes for surgical and procedural documentation in patient medical records. This role ensures coding compliance with all applicable regulations and guidelines to optimize reimbursement and maintain the integrity of clinical and financial data.

Key Responsibilities:

• Review operative reports and clinical documentation to assign appropriate CPT, ICD-10-CM, and HCPCS Level II codes.
• Ensure accurate capture of modifiers and adherence to payer-specific coding guidelines.
• Verify that all coded information supports medical necessity and aligns with regulatory requirements (e.g., CMS, AMA, and payer-specific policies).
• Query physicians for clarification or additional documentation when necessary.
• Maintain current knowledge of coding guidelines, compliance requirements, and regulatory updates.
• Collaborate with billing, compliance, and revenue cycle teams to resolve coding and claim issues.
• Participate in internal audits and quality assurance reviews.
• Meet productivity and accuracy benchmarks as established by the department.
• Protect patient confidentiality in accordance with HIPAA standards.

Education and Experience:

• High school diploma or equivalent required
• Minimum of 3 years of surgical coding experience (ambulatory surgery, hospital outpatient, or inpatient) preferred.

Certifications (required):

• Certified Professional Coder (CPC) – AAPC, or
• Certified Coding Specialist (CCS) – AHIMA, or
• Certified Outpatient Coder (COC) – AAPC

Skills and Competencies:

• Strong knowledge of medical terminology, anatomy, and surgical procedures.
• Proficiency in CPT, ICD-10-CM, and HCPCS Level II coding systems.
• Familiarity with electronic health record (EHR) systems and coding software.
• Excellent analytical, organizational, and communication skills.
• High attention to detail and ability to work independently with minimal supervision.
• Proficiency with EclinicalWorks (eCW) EMHR system preferred.
• Comprehensive understanding of OB/GYN terminology, anatomy and physiology
• Demonstrated experience coding OB global packages, delivers, gynecological surgeries and related procedures