Senior Clinical Coding Specialist - OR Surgery

About the role

This role supports accurate and compliant coding operations that directly impact revenue integrity and timely billing processes. The Senior Clinical Coding Specialist works collaboratively with internal teams to ensure high-quality coding and documentation standards.

Responsibilities

• Communicate effectively with coding team members, management, business office, and external customers.
• Provide detailed questions and feedback to management regarding coding issues, quality reviews, and training.
• Support internal and external requests for coding corrections or re-reviews.
• Report workflow or system issues promptly to management.
• Advance professional growth through continuing education, coding rounds, seminars, and literature review.
• Participate in team meetings and provide feedback on documentation challenges and compliance concerns.
• Contribute to discussions on coding clinic updates and process improvements.
• Maintain discharged-not-final-billed (DNB) and Pre-AR account thresholds as directed by leadership.
• Apply official coding guidelines, coding clinics, and departmental policies accurately.
• Review medical records and assign ICD-10-CM, CPT/HCPCS, modifiers, and other codes using 3M software, EPIC, and coding references.
• Initiate physician queries when documentation is unclear or insufficient.
• Uphold AHIMA ethical coding standards and HIPAA compliance rules.

Qualifications

• Required: Associate's Degree Health Information Management, Healthcare Administration, or related healthcare field.
• Required: 5 years Clinical coding experience for complex or multi-specialties.
• Prior experience working in a Teaching Hospital setting.
• Experience in Breast and Plastics, Surgical Oncology, Head and Neck, and/or Urology.
• A strong foundation in medical coding principles, including knowledge of ICD-10, CPT and HCPCS, along with practical experience in both inpatient and outpatient coding.
• One or more of the following certifications is required: RHIA, RHIT, CCS-Certified Coding Specialist, CCA, Certified Coder-AHIMA or AAPC.