SDS Coder / Charge Capture Auditor

We are seeking a detail-oriented and experienced Same Day Surgery (SDS) Medical Coder to accurately review, assign, and validate medical codes for outpatient surgical procedures. The ideal candidate has strong knowledge of CPT, ICD-10-CM, HCPCS Level II, and payer-specific coding guidelines to ensure accurate reimbursement and regulatory compliance.

Key Responsibilities

• Review operative reports, physician documentation, anesthesia records, and supporting medical records to assign accurate diagnosis and procedure codes.
• Accurately code outpatient and ambulatory surgery cases using ICD-10-CM, CPT, and HCPCS Level II coding systems.
• Ensure compliance with AAPC, AHIMA, CMS, NCCI edits, OIG regulations, and payer-specific coding guidelines.
• Identify missing, incomplete, or conflicting documentation and coordinate with providers for clarification when necessary.
• Apply appropriate modifiers to ensure accurate reimbursement.
• Review coding edits and resolve coding-related denials or claim rejections.
• Maintain productivity and quality standards established by the organization.
• Participate in coding audits, education sessions, and quality improvement initiatives.
• Stay updated on annual coding guideline changes, payer policies, and regulatory requirements.
• Collaborate with physicians, clinical staff, auditors, and revenue cycle teams to improve coding accuracy and documentation quality.

Qualifications

• Active CPC, CCS-P, CCS, or COC certification.
• Minimum of 2 years of Same Day Surgery (SDS) or Outpatient Surgery coding experience.
• Strong knowledge of:
  • CPT Coding
  • ICD-10-CM
  • HCPCS Level II
  • National Correct Coding Initiative (NCCI)
  • CMS Outpatient Prospective Payment System (OPPS)
• Experience with electronic health record (EHR) systems such as Epic, Cerner, Meditech, or similar EMRs is preferred.
• Familiarity with encoder software such as 3M Encoder or TruCode is an advantage.
• Strong analytical, problem-solving, and attention-to-detail skills.
• Excellent written and verbal communication skills.
• Ability to work independently while maintaining productivity and quality standards.

Preferred Experience

Experience coding surgical specialties including, but not limited to:

• General Surgery
• Orthopedic Surgery
• Gastroenterology
• Urology
• ENT
• Gynecology
• Ophthalmology
• Plastic Surgery
• Pain Management
• Cardiovascular Procedures

Key Competencies

• Medical Coding Accuracy
• Regulatory Compliance
• Clinical Documentation Review
• Revenue Cycle Management
• Critical Thinking
• Time Management
• Quality Assurance
• Collaboration and Communication
• Continuous Learning

Success Measures

• High coding accuracy and audit scores.
• Productivity goals consistently achieved.
• Low coding-related denial rate.
• Compliance with organizational and regulatory standards.
• Timely completion of coding assignments while maintaining quality.