Job Description

The HIM Surgery Coder coordinates the processing of fees for professional and facility services provided to patients in Surgery and Anesthesia and will provide back-up to Acute and ED for the purpose of reimbursement. Analyzes patient medical records to ensure that documentation by providers conforms to legal and procedural requirements.  Assigns specified codes to medical diagnoses, treatments and/or clinical procedures. Queries physicians and other healthcare providers to obtain complete and accurate documentation in the medical record.  Audits medical records to ensure proper coding completed and compliance with federal and state regulatory bodies.  Accurately follows coding guidelines and legal requirements to ensure compliance. 

 Essential Job Duties

·         Internal and external customer service

·         Coding; selecting and assigning proper codes

·         Abstracting; to compile statistical data and training

·         Auditing; to verify compliance

·         Monitors billing performance

·         Adhere and support WCH policy, procedures and practices

·         Acts as a coding resource to staff across all departments

·         Attends in-service training and education sessions, as assigned

·         Assist in compiling of statistical and quality data

Other Duties

·         Interdepartmental communication in verbal or written formats

·         Implement new systems as they occur

·         Reporting compliance issues to HIM Manager

·         Provide back-up for Acute and ED coding

·         Other work duties and projects as assigned by HIM Manager


·         High school diploma or equivalent required

·          Two or more years of previous hospital coding, or clinic experience, a recent graduate as a Certified Professional Coder

·         Must have good working knowledge of ICD-10 codes, HCPCS codes,

CPT procedure codes, and DRGs

·          Basic knowledge of anatomy and physiology

·          Knowledge of medical terminology

·          Ability to cross-train in Acute and ED coding

·          Strong computer skills

·          Coding certification or RHIT REQUIRED

Physical Requirements/Working conditions

·         Must be able to sit for long periods

·         Must be able to operate standard office equipment

·         Must be able to lift and carry up to 20 lbs

·         Must be able to work paying close attention to detail with frequent interruptions.

·         Ability to work in a fast pace environment.

·         Adequate hearing and vision for effective communication.

·         Follow complex instructions.

·         Think logically in following procedures and instructions.

·         Work well under stress, with interruptions and deadlines.

·         Effectively communicate dept needs to other departments.






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