Inpatient Surgical Coder "Complex spine coding highly desired"

ESSENTIAL FUNCTIONS

Reviews and abstracts clinical documentation from complex inpatient orthopedic and spine surgery records to assign accurate ICD-10-CM ICD-10-PCS DRG POA and discharge disposition codes.
Independently codes high-acuity inpatient orthopedic spine surgery cases including cervical thoracic and lumbar procedures revisions fusions instrumentation and neurological-related musculoskeletal procedures.
Provides real-time feedback and training for coding staff to improve coding quality and productivity.
Applies and validates accurate MS-DRG assignments while ensuring compliance with CMS UHDDS Official Coding Guidelines and payer-specific requirements.
Identifies coding trends documentation gaps and reimbursement risks and communicates findings to leadership.
Maintains productivity and quality standards while managing high-volume and high-complexity inpatient workloads.
Serves as a coding resource and mentor to less experienced coders and assists with onboarding and education initiatives.
Participates in policy development coding guideline interpretation and implementation of regulatory updates.
Acts as a liaison between coding staff leadership and external stakeholders.
Supports coding audits denials management appeals and quality improvement activities as assigned.

EDUCATION
High school diploma or GED required.
Associate or Bachelors degree in Health Information Management or related field preferred.
Must hold at least one of the following: RHIA RHIT CCS or CIC. CCS strongly preferred.

EXPERIENCE

Minimum of 45 years of IP facility/hospital coding experience required.
Minimum of 4-5 years of recent/current experience coding complex inpatient surgical cases required.
Extensive experience with inpatient coding (ICD-10-PCS and DRG assignment) required.
Demonstrated expertise in orthopedic surgical coding across multiple subspecialties.
Prior experience in auditing mentoring or leading coding teams strongly preferred.
Experience with denial management appeals and payer audits preferred.

REQUIREMENTS
Advanced to expert level knowledge of ICD-10-CM ICD-10-PCS DRG CPT and HCPCS coding systems.
Advanced understanding of DRG and APC reimbursement methodologies ortho anatomy and spine surgical techniques.
Proven ability to interpret and apply complex coding guidelines and regulatory updates.
Strong leadership skills with the ability to mentor and develop coding staff.
Prominent level of accuracy critical thinking and attention to detail.
Proficiency with coding software EMR systems and reporting tools.

KNOWLEDGE
In-depth knowledge of ICD-10-CM/PCS Official Guidelines UHDDS CMS regulations and payer-specific rules.
Advanced understanding of orthopedic anatomy surgical techniques and musculoskeletal disease processes.
Knowledge of compliance audit methodologies and revenue cycle impacts related to coding.
Familiarity with quality programs benchmarking and performance improvement initiatives.

SKILLS

Strong analytical and critical thinking skills for complex inpatient case resolution.
Effective communication skills when interacting with physicians CDI and interdisciplinary departments.
Ability to provide coding education and informal guidance to coding staff.
Exceptional attention to detail and organizational skills.

ABILITIES

Ability to lead coding staff in a collaborative and performance-driven environment.
Ability to manage multiple priorities including coding auditing and team support.
Ability to maintain strict confidentiality and compliance standards.
Ability to work independently while influencing team performance.

Required Experience:

IC