MEDICAL RECORDS CODER II

Duke University•Durham, NC

63d

About The Position

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together. About Duke Health's Patient Revenue Management Organization Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions. OCC Summary The Medical Records Coder II 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 and 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. Work Performed 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 on 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, 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.

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
High school diploma required.
RHIA certification- no experience required
RHIT certification- no experience required
CCS certification- one year of coding experience required
CPC or HCS-D certification- two 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 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 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, 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.