What you'll do:
The Certified Coding Specialist is responsible for accurate and compliant coding of complex orthopedic procedures across all care settings. This role directly impacts revenue integrity by ensuring optimal CPT/ICD-10 coding, minimizing denials, and supporting provider's documentation improvement.
Responsibilities/Duties:
Complex Surgical Coding
- Code high-complexity orthopedic and neurosurgical procedures
- Verifying all documentation is complete and compliant
- Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines.
- Follows coding conventions and ensure accurate assignment of:
- CPT (including add-on codes, modifiers, bundling rules)
- ICD-10 diagnoses supporting medical necessity
- Validate:
- Levels, laterality, approach (anterior/posterior)
- Instrumentation and graft usage
- Identify missed billable components (e.g., additional levels, hardware, biologics)
- Query provider for any necessary clarification related to unclear, unspecified or missing/incomplete documentation
- Apply payer-specific coding rules and edits
Denial Prevention & Root Cause Ownership
- Researches, analyzes, recommends, and facilitates a plan of action to correct discrepancies and prevent future coding errors:
- Review coding-related denials (medical necessity, bundling, documentation)
- Perform root cause analysis and trend identification
- Partner with RCM and vendor teams to implement corrective actions
- Develop coding edits and pre-bill review processes for high-risk procedures
Pre-Bill Quality Review
- Perform targeted pre-bill audits for:
- High-dollar orthopedic surgeries
- Multi-level and complex cases
- Ensure documentation supports:
- Medical necessity
- Procedure specificity
- Escalate documentation gaps prior to claim submission
Provider Documentation Improvement
- Partner with surgeons to improve documentation quality
- Provide targeted, case-based feedback:
- Missing elements impacting coding accuracy
- Opportunities to fully capture procedure complexity
- Support education on:
- Modifier usage
- Documentation specificity (levels, implants, approach)
Vendor Oversight & Coding Quality Control
- Audit external coding vendor performance (if applicable)
- Identify discrepancies between internal and vendor coding
- Provide feedback and enforce coding standards
- Support development of SOPs and coding guidelines
- Serves as primary resource and Spire Point of Contact (SPOC) between provider and vendor
Appeals
- Support appeals for coding-related denials
- Provide clinical/coding rationale and documentation validation
- Partner with AR teams on high-value accounts
Who you are:
Required Qualifications
- CPC, CCS, or equivalent certification (AAPC or AHIMA)
- 5+ years of surgical coding experience
- Deep knowledge of:
- NCCI edits and bundling rules
- Modifier usage (e.g., 22, 25, 50, 51, 57, 59, 62, 76)
- Orthopedic and Spine-specific CPT coding nuances
- Documentation requirements for Evaluation and Management services
- Experience with orthopedic or multi-specialty groups preferred
- Excellent organization skills
- Detailed oriented and comfortable with multi-tasking
- Ability to work in face-paced, results driven position
- Administer and uphold all the Company's values and policies and procedures.
- Continuously work towards the Company's goal and vision.
- Performs other duties as assigned.
Preferred Qualifications
- COSC specialty certification (AAPC)
- Experience working in a high-volume orthopedic/spine practice
- Exposure to vendor-managed RCM environments
- Familiarity with systems like ModMed or athenahealth
What we offer:
- Excellent growth and advancement opportunities
- Dynamic environment
- Access to a diverse network of practitioners
- Broad infrastructure of tools and programs to enhance the employee experience
- Competitive Compensation
- Generous PTO
- Benefits package: health, dental, vision, 401(k), etc.
We are an equal-opportunity employer. Qualified Applicants are considered for positions and are evaluated without regard to actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex, or gender (including pregnancy, childbirth, and related medical conditions), gender identity or gender expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable state or local law, genetic information, or any other characteristic protected by applicable federal, state, or local laws and ordinances (referred to as "protected characteristics").
The final pay offered to a successful candidate will be dependent on several factors that may include but are not limited to the type and years of experience within the job, the type of years and experience within the industry, education, etc.