Medical Coder- SDS (Same Day Surgery)

Job Description

We are seeking a same day surgery coder with at least three years of experience. The SDS coder is responsible for reviewing medical records for outpatient, or same day, surgical procedures, and assigning appropriate diagnostic and procedural codes (CPT and ICD-10) to ensure accurate billing and reimbursement.

Key responsibilities:

• Apply appropriate coding classification standards and guidelines to medical record documentation for accurate coding.
• Submit necessary provider queries to resolve documentation discrepancies.
• Perform quality assessment of records, including verification of medical record documentation.
• Review appropriate charges and make changes or recommendations based on the documentation.
• Responsible for researching errors or missing documentation from medical records to provide accurate coding processes.
• Abstracts and assigns the appropriate ICD-10-CM and CPT codes for all diagnoses and procedures performed in the outpatient and surgical settings as applicable.

Skills and Requirements

• 3+ years of facility outpatient surgery and observation experience and ideally be exposed to observation hours, injections, anesthesia, and infusion code assignment.
• Active AAPC or AHIMA certification
• Strong understand of surgery documentation requirements.
• Proficient in Microsoft Office, including Outlook, Excel, and Teams.
• Able to meet and maintain a 95% quality accuracy rate and productivity standards.
• Ability to apply official coding guidelines, NCCI edits, CPT Assistants, and Coding Clinics.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal employment opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment without regard to race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or the recruiting process, please send a request to [email protected].