Professional Coder

South Shore Health; Hingham (MA); On-site; USD 60,000 - 80,000; Full time

Job summary

South Shore Health System is seeking a Professional Surgical Coder I to accurately assign ICD-10-CM, CPT, and E/M codes for inpatient and outpatient services. This role reviews documentation, queries providers, and supports documentation improvement to ensure compliance and optimal reimbursement.

The successful candidate will have an associate degree in medical information technology, 2-3 years in a surgical practice, and CPC or CCS-P certification.

Qualifications

• Associate degree with coursework in medical terminology, anatomy and ICD-10-CM coding.
• 2–3 years in a surgical practice preferred.
• CPC or CCS-P certification required.

Responsibilities

• Assigns ICD-10-CM, CPT, and E/M codes for inpatient and outpatient services.
• Reviews documentation and queries providers to improve accuracy.
• Ensures coding complies with AHIMA standards and supports reimbursement.
• Collaborates with physicians and leadership on documentation improvement.
• Uses Epic and coding references to ensure accurate data entry.

Skills

ICD-10-CM coding

CPT coding

E/M coding

Medical record review

Education

Associate's Degree in Medical Information Technology

Tools

Epic

Job description

Job Description Summary

The Professional Surgical Coder I is responsible for the accurate and timely assignment of ICD-10-CM, CPT, and E/M codes for inpatient and outpatient services. This role reviews clinical documentation, assigns appropriate diagnoses and procedures, identifies documentation gaps, and queries providers as needed to ensure coding accuracy, compliance, and optimal reimbursement. The Professional Surgical Coder I collaborates with physicians and leadership to support documentation improvement and maintain high-quality coding standards.

Job Description

The Professional Surgical Coder I is responsible for the accurate and timely assignment of ICD-10-CM, CPT, and E/M codes for inpatient and outpatient services. This role reviews clinical documentation, assigns appropriate diagnoses and procedures, identifies documentation gaps, and queries providers as needed to ensure coding accuracy, compliance, and optimal reimbursement. The Professional Surgical Coder I collaborates with physicians and leadership to support documentation improvement and maintain high-quality coding standards.

ESSENTIAL FUNCTIONS

1. 1 - Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures performed. Assigns proper ICD-10CM and CPT-4 diagnostic and procedural codes to charts and related records by reference to designated coding manuals and other reference material.
   a - Codes 6-9 (# determined according to type of record coded) records per hour, consistently with 95% accuracy.
   b - Assigns diagnostic and procedural codes for physicians in the inpatient, outpatient, and observation setting.
2. 2 - Identifies any and/or all complications or comorbidities.
   a - Applies sequencing guidelines based on medical record information provided according to official coding rules
3. 3 - Assesses the appropriateness of medical record documentation to ensure that it supports the procedure(s), diagnosis', as well as complications and/or comorbid conditions documented. Consults with the appropriate provider to clarify medical record information.
   a - Identifies any documentation inadequacies with provider and clarifies medical record information with courtesy and tact.
   b - Retrieves any and all records corresponding to surgical cases including laboratory/path reports to ensure accurate assignment of ICD-10-CM and CPT-4 codes.
   c - Ensures accurate, correctly coded information is entered intoEpic
4. 4 - Answers provider/clinician questions regarding coding principles,
   a - Assists with coding queries for claims appeals and resolution.
   b - Refer ancillary department coding questions to Professional Coding Manager
5. 5 - Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature and so forth.
   a - Utilizes professional affiliations, etc., in order to maintain current in professional developments.
   b - Attends all pertinent coding seminars and manager assigned training.
   c - Utilize all available hospital-provided electronic resources
6. 6 - Works collaboratively with appropriate team members to recommend strategies for process improvement
7. 7 - Assists in responses to billing review requests
8. 8 - Abides by Standards of Ethical Coding as set forth by American Health Information Management Association (AHIMA)
9. 9 - Meets coding, quality and productivity standards.
10. 10 - Performs all job functions in compliance with applicable federal, state and local laws as well as hospital policy and procedures

JOB REQUIREMENTS

Minimum Education - Preferred

Equivalent to an Associate's Degree in Medical Information Technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD-10-CM coding required and prospective payment preferred).

Minimum Work Experience

Two to three (2-3) years in a surgical practice preferred.

Required Certifications

CPC - Certified Professional Coder OR CCS-P Certified Coding Specialist- Physician Based

Required additional Knowledge and Abilities

Strong proficient computer and data entry skills to gather and interpret data.

Strong analytical skills to gather and interpret data.