Profee & Facility General Surgery Medical Coder

Profee & Facility General Surgery Medical Coder

This fully remote position is designed for an experienced medical coder specializing in professional and facility general surgery records. You will review complex medical documentation and accurately assign diagnostic and procedural codes using established coding systems and guidelines. The role covers a broad range of surgical procedures while requiring strong knowledge of anatomy, physiology, pharmacology, reimbursement, and documentation standards. You will contribute directly to coding accuracy, quality, compliance, and efficient healthcare revenue-cycle operations for multiple clients. Beyond daily production, you will support coding education, participate in professional roundtables, and share knowledge with colleagues. The environment is collaborative and quality-driven, with opportunities to work across different client assignments and coding specialties. This is an excellent opportunity for a certified coding professional seeking a stable remote role with meaningful responsibility and continued professional development.

Accountabilities

• Review outpatient, physician, and emergency-room medical records to identify relevant diagnoses and procedures associated with each healthcare encounter.
• Assign principal and secondary diagnoses and procedures in accordance with UHDDS definitions, applicable coding guidelines, and client requirements.
• Ensure appropriate DRG assignment and accurately abstract required information from medical records.
• Assign diagnosis, evaluation and management (E&M), and CPT codes following established coding principles and documentation requirements.
• Maintain consistently high productivity and quality performance while entering coded charts in real time throughout scheduled shifts.
• Review documentation for ambiguity or conflicting information and obtain appropriate physician clarification using established client guidelines.
• Maintain current knowledge of ICD-10-CM, CPT, Coding Clinic, CPT Assistant, and Official Guidelines for Coding and Reporting.
• Participate in team meetings, required training, coding education, and shadowing or mentoring activities for other coders when requested.
• Support multiple client assignments and demonstrate flexibility to ensure required classification hours and service levels are achieved.
• Participate in Coding Roundtables by presenting relevant materials, articles, coding updates, and current Health Information Management topics.
• Complete assigned education modules and maintain all required professional coding credentials in active status.
• Communicate professionally and effectively with colleagues, clients, and other stakeholders while contributing to a positive and respectful team environment.
• Perform additional coding, education, quality, or operational responsibilities as assigned.

Requirements

• At least 3 years of experience coding professional-fee and facility general surgery charts, with exposure to a broad variety of surgical procedures.
• At least 2 years of experience coding professional-fee and facility ophthalmology and multispecialty charts.
• At least 3 years of experience coding diagnoses, evaluation and management services, and CPT procedures.
• Demonstrated experience coding procedures such as tonsillectomy, tumor excision, tracheostomy, lymph node removal, thyroid lobectomy, skin grafts, laminotomy, facetectomy, foraminotomy, herniated-disk repair, vertebral augmentation, spinal fixation, allograft procedures, and other complex surgeries.
• Active certification or credential such as CPC, COC, CIC, CCA, CCS, CCS-P, RHIT, or RHIA.
• Extensive knowledge of ICD-10-CM, CPT, coding principles and guidelines, reimbursement systems, and federal, state, and payer-specific documentation, coding, and billing requirements.
• Strong understanding of medical terminology, anatomy, physiology, surgical technology, pharmacology, and disease processes.
• High level of coding accuracy, attention to detail, and ability to manage complex medical records efficiently.
• Excellent verbal and written communication skills, with the ability to communicate clearly and professionally.
• Strong interpersonal skills and ability to collaborate effectively with colleagues and clients in a remote environment.
• Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
• Experience with Epic and 3M coding systems is preferred; training may be available.
• Ability to successfully complete a coding proficiency assessment.
• Ability to work independently while meeting productivity, quality, scheduling, and client-specific requirements.
• Comfortable with prolonged computer-based work, keyboarding, screen use, and extended periods of sitting.

Benefits

• Fully remote work environment within the United States.
• Hourly compensation of $28$32 per hour, depending on factors such as location, experience, education, certifications, and market conditions.
• Healthcare benefits, subject to eligibility requirements.
• 401(k) retirement plan.
• Paid time off, subject to eligibility requirements.
• Opportunities for ongoing coding education and professional development.
• Exposure to multiple clients, specialties, and coding environments.
• Opportunities to participate in coding roundtables, knowledge sharing, and team education initiatives.
• Collaborative environment focused on accuracy, quality, professionalism, and continuous learning.