Surgical Coder / Auditor

Surgical Coder / Auditor

Review operative and clinical documentation to assign appropriate CPT, ICD-10-CM, ICD-10-PCS, and modifiers for orthopedic surgeries. Assign and validate MS-DRGs and APR-DRGs for inpatient encounters based on documentation and coding guidelines. Audit coding and billing work performed by third-party vendors to ensure accuracy, compliance, and adherence to hospital policies. Analyze and resolve insurance denials related to coding, documentation, and DRG assignment. Prepare and submit appeals with supporting documentation for denied claims, including DRG downgrades. Collaborate with physicians, clinical staff, and external vendors to clarify documentation and resolve coding discrepancies. Maintain current knowledge of payer policies, coding guidelines, DRG grouping logic, and orthopedic surgical procedures. Track and report coding accuracy, denial trends, and audit findings to leadership. Assist in training and onboarding of new coding staff or vendors as needed. Ensure compliance with HIPAA, CMS, and other regulatory requirements. Other duties as assigned.

Qualifications

Education & Training : High school diploma or equivalent required, Associates or Bachelor's Degree preferred. Licenses / Certifications : Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or Certified Professional Coder (CPC) required. Orthopedic coding certification preferred (e.g., COSC). Experience : Minimum 35 years of surgical coding experience, with at least 2 years in orthopedics. Strong knowledge of CPT, ICD-10-CM, ICD-10-PCS, HCPCS, and DRG grouping systems. Experience with DRG assignment and validation in a hospital setting. Familiarity with orthopedic terminology and procedures. Experience auditing coding work and handling insurance denials and appeals. Proficiency in EHR and billing systems (Epic, Cerner, or similar), CPSI preferred. Excellent written and verbal communication skills. Detail-oriented with strong organizational and analytical abilities.