Coder II

Accountabilities:

• • Review and interpret medical records and clinical documentation to accurately assign ICD-10-CM diagnosis and CPT procedure codes in accordance with applicable coding guidelines and regulations.
  • Abstract relevant clinical and demographic information while ensuring accurate and complete coding for scheduled and unscheduled surgical procedures.
  • Use practice management systems and hospital medical record platforms to validate patient information, services performed, and documentation required for appropriate coding and billing.
  • Review operative reports and complex clinical documentation to select codes based on the procedures actually documented.
  • Apply CPT, ICD-10-CM, HCPCS Level II, modifiers, NCCI edits, global surgical guidelines, and payer-specific requirements consistently.
  • Identify and resolve coding edits, documentation discrepancies, and potential compliance concerns, escalating complex cases when appropriate.
  • Coordinate with physicians and clinical staff to obtain missing documentation and provide clarification regarding coding-related issues.
  • Educate and support providers and clinical teams on appropriate documentation and coding practices to promote accurate billing and regulatory compliance.
  • Conduct research into unfamiliar procedures, coding guidelines, payer requirements, and other issues affecting coding accuracy.
  • Collaborate with Coding leadership, Authorization, Revenue Cycle, providers, and other operational teams to resolve issues effectively.
  • Maintain productivity, accuracy, quality, and turnaround expectations while working independently with limited supervision.
  • Adapt to multiple specialties, changing payer requirements, and evolving coding standards while maintaining strong professional judgment.

  Requirements:

  • 3–5 years of professional medical coding experience, ideally within a multispecialty environment involving orthopedics, surgery, pain management, spine, or other complex procedural coding.
  • High school diploma, GED, or equivalent working knowledge preferred.
  • Current professional coding certification such as CPC, CCS, COC, or equivalent; certification through AHIMA or AAPC is preferred/required according to organizational standards.
  • Demonstrated expertise in CPT, ICD-10-CM, HCPCS Level II, modifiers, NCCI edits, global surgical guidelines, and payer-specific coding requirements.
  • Strong experience reviewing operative reports and clinical documentation and accurately assigning codes based on documented services.
  • Experience resolving coding edits and documentation discrepancies; exposure to coding audits, payer guidelines, NCCI edits, and physician queries is strongly preferred.
  • Strong analytical, research, critical-thinking, and problem-solving abilities.
  • Exceptional attention to detail and a strong commitment to coding accuracy, compliance, and data integrity.
  • Excellent written and verbal communication skills, including the ability to explain coding concerns and request documentation clarification professionally.
  • Ability to work independently, prioritize competing demands, and consistently meet productivity, quality, and turnaround expectations.
  • Strong organizational skills, accountability, sound judgment, and adaptability.
  • Ability to work effectively with physicians, clinical teams, coding leadership, authorization, revenue cycle, and other operational stakeholders.
  • Comfortable working remotely and managing confidential medical information in accordance with applicable privacy and compliance requirements.

  Benefits:

  • Full-time remote work with a Monday–Friday schedule.
  • Comprehensive medical, dental, and vision insurance.
  • 100% employer-paid life insurance.
  • 401(k) plan with employer match.
  • Benefits begin on the first day of the month following the hire date for eligible full-time employees.
  • Generous paid sick and vacation time.
  • 7 paid holidays annually.
  • Professional growth and career advancement opportunities.
  • Employee referral reward program.
  • Collaborative, patient-focused healthcare environment.
  • Opportunities to develop expertise in complex procedural and orthopedic coding.