Medical Records Coder II-Inpatient
Duke UniversityAbout the role
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.
Patient Revenue Management Organization
Pursue your passion for caring with the Patient Revenue Management Organization, which is the 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 for Duke Health.
This position is 100% remote. All Duke University remote workers must reside in one of the following states:
North Carolina, Alabama, Arizona, Connecticut, District of Columbia, Florida, Georgia, Illinois, Iowa, Kentucky, Louisiana, Maine, Michigan, Missouri, Montana, New Hampshire, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington.
*Now offering a $10,000 sign-on bonus that will pay out in 4 equal installments over 24 months—6-month increments.
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 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.
Knowledge,Skills and Abilities
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
Level Characteristics
N/A
Minimum Qualifications
Education
High school diploma required.
Experience
RHIA certification—no experience
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