Job Description

Mission Statement

To consistently pursue excellence in service, quality, comfort, and convenience to create an unparalleled experience for patients, their families, and our physicians.

Vision Statement

Through strong partnerships with high-quality physicians and a steadfast commitment to excellence, Omega Hospital will remain a premier surgical hospital for patients, physicians, and employees.

Position Summary

The Medical Coder is responsible for all coding functions for Omega Hospital, including professional and technical services across surgical and pre-operative encounters. This role supports accurate, compliant, and optimized reimbursement by ensuring complete and precise coding for hospital services, anesthesia, first assist, and related professional components.

This is a remote, in-house position requiring close collaboration with physicians, anesthesia providers, scheduling, and the billing team. The coder will also support coding audits, denials, and appeals, and play a key role in maintaining compliance while optimizing revenue integrity.

Estimated surgical volume is approximately 250 cases per month.

Essential Duties & Responsibilities

Coding & Documentation

• Perform complete coding for all Omega Hospital services, including:
• Hospital (technical/facility) components
• Professional services, including Anesthesia and First Assist
• Pre-operative and related encounters
• Assign accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes in accordance with:
• AMA, CMS, and payer-specific guidelines
• Federal and state regulations
• Omega Hospital compliance policies
• Review operative reports, physician documentation, and clinical records to ensure coding accuracy, completeness, and appropriate specificity.

Systems & Workflow

• Perform all coding activities within CPSI and related billing software platforms.
• Utilize Omega Hospital-provided equipment (computer and related tools).
• Work closely with:
• Surgeons and proceduralists
• Anesthesia providers
• Scheduling staff
• Billing and revenue cycle teams to resolve documentation gaps, clarify procedures, and ensure timely claim submission.

Revenue Integrity, Audits & Appeals

• Participate in and support internal and external coding audits.
• Assist with coding-related denials, appeals, and payer inquiries.
• Identify documentation or coding trends that may impact compliance or reimbursement and proactively communicate findings to leadership.
• Support process improvements to enhance accuracy, efficiency, and compliance.

Compliance & Confidentiality

• Maintain strict adherence to HIPAA, Joint Commission standards, and Omega Hospital compliance policies.
• Protect the confidentiality and security of all patient health information.
• Stay current on coding updates, regulatory changes, and payer guidance relevant to surgical hospitals and anesthesia services.

Professional Expectations

• Demonstrate strong communication skills, responsiveness, and accountability in a remote environment.
• Maintain consistent availability to meet workflow demands and collaborate effectively with internal teams.
• Exhibit a high level of professionalism, attention to detail, and work ethic.

PATIENT POPULATION SERVED

This is a non-clinical position serving the general patient population through accurate documentation and coding of healthcare services.

Minimum Qualifications

EDUCATION, EXPERIENCE & QUALIFICATIONS

• High school diploma or equivalent.
• Formal training or certification in medical coding (CPC, CCS, or equivalent experience).
• Minimum 2 years of hands-on medical coding experience, preferably including:
• Surgical services
• Inpatient and outpatient hospital coding
• Anesthesia and/or professional fee coding
• Ability to work independently in a remote setting while meeting deadlines and productivity expectations.
• Successful completion of pre-employment background screening requirements.

Preferred Qualifications

• Coding certification (CPC, CCS, CCS-P, or equivalent).
• Experience with CPSI or similar hospital information systems.
• Experience in a surgical hospital or ASC environment.
• Familiarity with coding audits, appeals, and payer compliance.

PHYSICAL DEMANDS & WORK ENVIRONMENT

• Remote office environment.
• Prolonged periods of computer use.
• Occasional flexibility in schedule may be required to support operational needs.

ADA & CORPORATE COMPLIANCE

Omega Hospital complies with the Americans with Disabilities Act (ADA) and provides reasonable accommodations where required. Employees are expected to adhere to all Omega Hospital compliance policies, Code of Conduct, and confidentiality requirements.

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