Medical Records Coder II-Inpatient

Duke Careers • Durham, NC

11d • Onsite

About The Position

Established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke Primary Care. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke’s reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.Please note: This is NOT a remote work opportunity for candidates that reside in North Carolina, South Carolina, Georgia, Florida, Texas, or Virginia. The Medical Records Coder II (Inpatient) is a certified Coder. Coordinate/review the work of subordinate employees and assist with the training and continuing education programs. Code medical records utilizing ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures, and appropriate/optimal reimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures.

Requirements

• High school diploma required.
• RHIA certification-no experience required
• RHIT certification-no experience required
• CCS certification-Two years of coding experience required (Must be in the service the applicant is applying for)
• CPC or HCS-D certification, years of coding experience required
• Must hold one of the following active/current certifications: Registered Health Information Administrator (RHIA) Hospital Coding, Registered Health Information Technician (RHIT) Hospital Coding Certified Coding Specialist (CCS) Hospital Coding, Certified Professional Coder (CPC), Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding

Responsibilities

• Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, and/or CPT coding conventions.
• Coordinate/review the work of designated employees. Ensure quality and quantity of work performed through regular audits.
• Assist with research, development, and presentation of continuing education programs on areas of specialization.
• Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding conventions. Sequence the diagnoses and procedures using coding guidelines. Ensure DRG/APC assignment is accurate. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
• Consult with and educate physicians on coding practices and conventions to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
• Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), etc.
• Assist with special projects as required.
• Perform other related duties incidental to the work described herein.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees