Profee & Facility General Surgery Medical Coder

Accountabilities

• Review outpatient, physician, and emergency-room medical records to identify relevant diagnoses and procedures associated with each healthcare encounter.
• Assign principal and secondary diagnoses and procedures in accordance with UHDDS definitions, applicable coding guidelines, and client requirements.
• Ensure appropriate DRG assignment and accurately abstract required information from medical records.
• Assign diagnosis, evaluation and management (E&M), and CPT codes following established coding principles and documentation requirements.
• Maintain consistently high productivity and quality performance while entering coded charts in real time throughout scheduled shifts.
• Review documentation for ambiguity or conflicting information and obtain appropriate physician clarification using established client guidelines.
• Maintain current knowledge of ICD-10-CM, CPT, Coding Clinic, CPT Assistant, and Official Guidelines for Coding and Reporting.
• Participate in team meetings, required training, coding education, and shadowing or mentoring activities for other coders when requested.
• Support multiple client assignments and demonstrate flexibility to ensure required classification hours and service levels are achieved.
• Participate in Coding Roundtables by presenting relevant materials, articles, coding updates, and current Health Information Management topics.
• Complete assigned education modules and maintain all required professional coding credentials in active status.
• Communicate professionally and effectively with colleagues, clients, and other stakeholders while contributing to a positive and respectful team environment.
• Perform additional coding, education, quality, or operational responsibilities as assigned.

Requirements

• At least 3 years of experience coding professional-fee and facility general surgery charts, with exposure to a broad variety of surgical procedures.
• At least 2 years of experience coding professional-fee and facility ophthalmology and multispecialty charts.
• At least 3 years of experience coding diagnoses, evaluation and management services, and CPT procedures.
• Demonstrated experience coding procedures such as tonsillectomy, tumor excision, tracheostomy, lymph node removal, thyroid lobectomy, skin grafts, laminotomy, facetectomy, foraminotomy, herniated-disk repair, vertebral augmentation, spinal fixation, allograft procedures, and other complex surgeries.
• Active certification or credential such as CPC, COC, CIC, CCA, CCS, CCS-P, RHIT, or RHIA.
• Extensive knowledge of ICD-10-CM, CPT, coding principles and guidelines, reimbursement systems, and federal, state, and payer-specific documentation, coding, and billing requirements.
• Strong understanding of medical terminology, anatomy, physiology, surgical technology, pharmacology, and disease processes.
• High level of coding accuracy, attention to detail, and ability to manage complex medical records efficiently.
• Excellent verbal and written communication skills, with the ability to communicate clearly and professionally.
• Strong interpersonal skills and ability to collaborate effectively with colleagues and clients in a remote environment.
• Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
• Experience with Epic and 3M coding systems is preferred; training may be available.
• Ability to successfully complete a coding proficiency assessment.
• Ability to work independently while meeting productivity, quality, scheduling, and client-specific requirements.
• Comfortable with prolonged computer-based work, keyboarding, screen use, and extended periods of sitting.

Benefits

• Fully remote work environment within the United States.
• Hourly compensation of $28–$32 per hour, depending on factors such as location, experience, education, certifications, and market conditions.
• Healthcare benefits, subject to eligibility requirements.
• 401(k) retirement plan.
• Paid time off, subject to eligibility requirements.
• Opportunities for ongoing coding education and professional development.
• Exposure to multiple clients, specialties, and coding environments.
• Opportunities to participate in coding roundtables, knowledge sharing, and team education initiatives.
• Collaborative environment focused on accuracy, quality, professionalism, and continuous learning.