MEDICAL RECORDS CODER II

Duke Careers•Durham, NC

2d•Remote

About The Position

The Medical Records Coder II is a certified coder responsible for coordinating and reviewing the work of subordinate employees and assisting with training and continuing education programs. This role involves coding medical records using ICD-10-CM and CPT-4 coding conventions, reviewing medical records to ensure specificity of diagnoses, procedures, and appropriate/optimal reimbursement for hospital and/or professional charges, and abstracting information from medical records following established methods and procedures. This position is 100% remote and requires the employee to reside in North Carolina, Virginia, South Carolina, Tennessee, Florida, or Texas.

Requirements

Advanced ICD-10-CM & CPT-4 coding conventions
Anatomy and Physiology
Medical Terminology
Extensive DRG/APC reimbursement knowledge
Coding software familiarity
Effective written and verbal communication skills
Data entry/CRT
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 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 in areas of specialization.
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and 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 in order 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 and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
Maintain a thorough understanding of medical record practices, standards, regulations, the 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.