PB -Coder III - Neuro Surgery

Grady Health System; Atlanta (GA); On-site; USD 60,000 - 86,000; Full time

Benefits offered by this job

Health & dental benefits

Retirement plan with employer matching

Paid time off

Job summary

Grady Health System is seeking a skilled Coder III to review outpatient clinical documentation via Epic and 3M CAC for ICD-10-CM and CPT coding. The role requires strong surgical/ancillary coding experience and the ability to query physicians for clarifications.

You will work to optimize reimbursements, compile documentation, and ensure compliance with Medical Necessity requirements, while collaborating with physicians and staff across departments.

Qualifications

• Four years of coding experience required
• Two years in a Surgical/Ancillary Diagnostic discipline
• Or 1 year with specialty coding certification in a Surgical/Ancillary Diagnostic discipline
• Knowledge of CPT and ICD-10 coding conventions

Responsibilities

• Code complex surgical and diagnostic records with CPT/ICD-10-CM
• Evaluate documentation to optimize reimbursement
• Query physicians when documentation is incomplete
• Notify non-compliance with Medical Necessity requirements
• Corrects claim errors and coding denials
• Compile documentation prior to coding review
• Work independently to resolve issues and meet accuracy targets

Skills

Surgical coding

ICD-10-CM

CPT coding

3M CAC

Epic coding

Communication skills

Tools

Epic

3M CAC

Job description

Whatever the role, everyone at Grady is part of something bigger. Choosing a career at Grady is choosing to be part of a legacy of service and commitment to our communities. If you want to make a difference, we want to hear from you.

Job Summary

The Coder is responsible for reviewing outpatient clinical documentation via Epic and 3M CAC for assignment of ICD-10-CM diagnoses and CPT-4/HCPCS procedure coding systems. Through knowledge of coding conventions and guidelines. Ability to address commonly applied modifiers for hospital outpatient accounts. Extracts pertinent information from clinical notes, operative notes, radiology reports, laboratory reports, (including Pathology), procedure records, specialty forms, etc. Determines complex code assignment pertinent to emergency visits and diagnostic workups.

CODER III

• The Multispecialty Coder must possess a strong surgical specialty background in some of the following specialties: Neurosurgery, Trauma, Ortho, Plastic Surgery, etc.

• Codes complex surgical, special procedures, observation records, inpatient records,medical, diagnostic, procedural, and/or recurring records within. Highly complex surgeries may require research and referencecheckingto ensure accuracyof problematiccoding.

• Evaluates medical record documentation, paper charge, discharge disposition, ICD-10 andCPTcodingtooptimizereimbursementbyensuringthatmedical,diagnosticandproceduralcodesand other documentationaccuratelyreflectandsupportthevisit.

• Compilesnecessarydocumentationpriortocodingreview;whendocumentationisnotavailable,performs the appropriate steps to obtain the necessary documentation per the department'spoliciesand procedures.

• Works independently to resolve issues, applying root cause analyses to determine steps required for timely resolution.Meetsestablishedproductivityandaccuracystandards.

• Demonstrate the ability to communicate effectively and professionally in interactions with physicians, management, and staff.

• Queries physicians when code assignments are not straightforward or documentation isinadequate,ambiguous,orunclearforcodingpurposes; offersphysicianopportunitytosubmitcorrecteddocumentation.

• Notifies appropriate individuals of potential non-compliance with Medical Necessityrequirementsandwhen servicesare non-coveredornot payable,asappropriate.

• Corrects failed claim errors to billing edits, coding denials, qualitymanagement data edits and/or other errors identified through various auditing or billing process.

QUALIFICATIONS:

Four(4)yearsof codingexperiencerequired,

two (2) years of experience must be in a Surgical/Ancillary Diagnostic discipline

or 1 year of experience with specialty coding certification in a Surgical/Ancillary Diagnostic discipline. Knowledge of CPT and ICD-10 coding conventions.

CERTIFICATION: Certified Coding Specialist

Remote: Must live in Georgia

Ability to multi-task, prioritize needs, and meets required timelines.

Good interpersonal and communication skills in dealing with physicians and other healthcare professionals.

Ability to research the root causes related to the inability to code and drop accounts.

Core Competencies

These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

• Patient-Centered Care - Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
• Integrity & Accountability - Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
• Collaboration & Teamwork - Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
• Communication - Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
• Respect & Inclusion - Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
• Quality & Safety - Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.
• Adaptability & Resilience - Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
• Continuous Improvement - Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
• Leadership & Professionalism - Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
• Employee Experience Focus - Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards

At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

• Health & Wellness: Medical, dental, vision, and prescription drug coverage.
• Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.
• Work-Life Balance: Paid time off, holidays, and family leave benefits.
• Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.
• Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady's Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady?

Grady Health System is more than a hospital - we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don't just work, we make an impact.

Equal Opportunity Employer Statement:

Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.