Job Title: Medical Coding QA – Surgery Coding Specialist

Job Type: Full-Time

Experience Required: Minimum 9 years in Surgery Coding

Reports To: Senior Manager – Coding

Job Summary:

We are seeking a highly experienced Medical Coding QA Specialist with a strong background in surgery coding and quality assurance. The ideal candidate will have at least 9 years of hands-on experience in surgery coding and a deep understanding of payer-specific and federal insurance guidelines (Medicare, Medicaid, Commercial payers). This role requires a keen eye for detail, an analytical mindset, and proven experience in ensuring coding accuracy and compliance with industry standards.

Key Responsibilities:

1. Coding QA Audits & Accuracy Oversight

• Perform comprehensive quality audits on surgical coding across specialties such as general surgery, orthopedic, gastroenterology, neurosurgery, cardiovascular, urology, ENT, and OB-GYN.
• Audit both pre-bill and post-bill coding to ensure accuracy, specificity, and appropriate modifier usage.
• Verify that coding aligns with official coding guidelines, client protocols, and federal regulations.
• Identify undercoding, overcoding, and non-compliance issues; communicate with coders to clarify ambiguities.

2. Advanced Coding Expertise

• Thoroughly review operative and procedure notes, extract the most specific diagnosis and procedure codes.
• Assign and validate CPT®, ICD-10-CM, and HCPCS codes per industry-standard rules.
• Ensure appropriate use of modifiers (e.g., 22, 50, 51, 59, 76, 78, 79, etc.) in surgical billing.
• Keep updated with changes in NCCI edits, LCD/NCD policies, and CMS payer rules.

·        Expert-level command of CPT® surgical codes (10021–69990 range) and Radiology section (70000) series including:

Integumentary, Musculoskeletal, Respiratory, Cardiovascular, Digestive, Genitourinary, Nervous Systems & Radiology section.

3. Insurance & Compliance Knowledge

• Apply payer-specific rules for Medicare, Medicaid, BCBS, Aetna, UHC, Humana, and other commercial carriers.
• Evaluate coding quality in accordance with HIPAA, CMS, and OIG guidelines.
• Support accurate coding to reduce denials, rejections, and prevent compliance risks.

4. QA Reporting & Root Cause Analysis

• Prepare detailed audit reports including error rates, coder performance trends, and compliance metrics.
• Conduct root cause analysis for repetitive errors and work with training teams to drive improvement.
• Provide coaching, re-education, and corrective feedback to coders based on audit findings.

5. Training & Process Improvement

• Collaborate with the training team to develop and deliver coding refresher training and payer update sessions.
• Participate in internal quality initiatives, process enhancements, and technology upgrades.
• Assist in the development of audit tools, QA templates, SOPs, and coding manuals.

Core Competencies & Technical Skills Required:

• Expert-level command of CPT® surgical codes (10021–69990 range), including:
• Integumentary, Musculoskeletal, Respiratory, Cardiovascular, Digestive, Genitourinary, Nervous Systems
• Modifier usage and complex surgical bundling/unbundling principles
• Extensive experience reading and abstracting operative reports
• Deep understanding of insurance guidelines for:
• Global periods
• Medical necessity documentation
• Prior authorization rules
• Familiarity with coding tools: 3M, EncoderPro, Optum, FindACode, and EHRs like Epic, Cerner, Athena, etc.
• Strong documentation and analytical skills to support coder feedback and compliance reviews

Educational & Certification Requirements:

• Required: CPC®, CCS, or equivalent certification (AAPC or AHIMA)
• Preferred: CPMA®, COC®, or CIC®
• Associate/Bachelor’s degree in Health Information Management or equivalent healthcare field (preferred)

Preferred Experience:

• Prior experience with denial management, appeals support, and insurance audit response
• Hands-on experience in surgical billing and revenue integrity audits
• Previous experience working in US healthcare revenue cycle, particularly in outpatient surgery centers or hospital coding QA teams