Coder II - Anesthesia

Major Responsibilities

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings, ensuring expert application of modifiers and E/M guidelines, or;
• Perform entry-level facility coding for simple outpatient encounters (e.g., diagnostic imaging, labs) and basic inpatient services (e.g., uncomplicated admissions, short stays) using ICD-10-CM and ICD-10-PCS, where applicable
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Licensure, Registration, And/or Certification Required

• An active coding certification issued by the American Academy of Coders (AAPC) OR American Health Information Management Association (AHIMA);
• Dual certifications, preferred

Education Required

• High School Diploma or Equivalent required
• Completion of an accredited medical coding or HIM program (or equivalent experience)

Experience Required

• For Entry-Level Roles (Basic Inpatient/Simple Outpatient):
  • Foundational experience in facility coding (via education, externship, or applied work) covering basic outpatient and basic inpatient records.
  • Experience with Epic or similar electronic health record systems is a plus
• For Proficient Roles (Complex Professional Coding):
  • Minimum of 3-5 years of direct professional fee coding experience in a multi-specialty environment is required
  • Experience with professional procedural coding (e.g., surgical, interventional procedures) is preferred
  • Experience with Epic or similar electronic health record systems is required

Knowledge, Skills & Abilities Required

• Proficient knowledge of medical terminology, anatomy, and pathophysiology
• Advanced proficiency in CPT/HCPCS and ICD-10-CM/PCS coding systems
• Basic understanding of facility payment methodologies (MS-DRGs) as they apply to simple encounters
• Strong analytical skills, attention to detail, and ability to context-switch between different coding guidelines
• Ability to work independently, manage a varied workload, and meet deadlines in a fast-paced environment

Physical Requirements And Working Conditions

• Exposed to normal office environment in a remote work setting
• Job may require occasional travel for training or meetings, therefore, may be exposed to road and weather hazards
• May need to be able to lift up to 40 lbs. occasionally (e.g., equipment)
• Sits the majority of the workday, but also may lift, reach, and bend throughout the day
• Operates all equipment necessary to perform the job
• This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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