MEDICAL RECORDS CODER II

Duke Careers • Durham, NC

1d

About The Position

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 ensure 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

• 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 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, 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