Coder II (Outpatient-SDS)

About the role

The Coder II is primarily responsible for coding outpatient surgical, interventional radiology/cardiology procedures, and Observation accounts. This position involves reviewing the entire patient record, including electronic records, to assign appropriate codes for:

• Outpatient: Day patients
• Cardiac catheterization lab
• Other interventional radiology
• Observation patients
• Labor and Delivery Observation

Coding must be complete, timely, and in accordance with CMS, Coding Clinic Guidelines, CPT Assistant, and organizational policies. The Coder II is also responsible for entering charges for Observation hours, infusions, injections, and bedside procedures for Observation and Labor and Delivery Observation accounts, following all regulatory requirements. Strong knowledge of appropriate modifier use is required.

Responsibilities

• Assign accurate codes for outpatient surgical, interventional radiology/cardiology, and Observation accounts.
• Review patient records, including electronic records, for completeness and accuracy.
• Enter charges for Observation hours, infusions, injections, and bedside procedures.
• Ensure compliance with CMS, Coding Clinic Guidelines, CPT Assistant, and organizational policies.

Requirements

• High School Diploma or GED (preferred).
• Completion of AHIMA-approved coding program.
• Two years of coding experience in an acute care facility outpatient surgery department, stand-alone ambulatory surgery center, or emergency/urgent care center using ICD-10-CM, CPT coding, and APC grouper.
• Two years of experience manually charging on ER, Observation, or Labor and Delivery accounts following regulatory and facility guidelines (preferred).

Qualifications

• Current Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) certification.
• Proficiency in data entry and medical terminology (basic and advanced).
• Knowledge of human anatomy and physiology, pathology, and microbiology.
• Familiarity with ICD-10-CM and CPT 4.
• Ability to interpret medical record documentation for accuracy and completeness.
• Proficiency in computer use.

Pay

$28.52 - $42.78 per hour. The posted pay range reflects the lowest to highest pay available for this position at the time of posting and may be subject to change. Salary offers are determined by the candidate’s relevant experience and skills. For per diem positions, a standard rate is used based on market data and not the candidate’s individual experience.