Please note: Remote Opportunity: This position is open to non-exempt candidates in North Carolina, Virginia, South Carolina, Tennessee, Florida, and Texas.
*Now offering a ***$10,000.00 Commitment Bonus (4 equal installments over 24 months- 6-month increments)
General Description of the Job Class
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.
Duties and Responsibilities of this Level
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 in 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 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, 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, and 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.
Required Qualifications at this Level
Education:
High school diploma required.
Experience:
- RHIA certification-no experience required
- RHIT certification-no experience required
- CCS certification-Two years of coding experience required (Must be in the service applicant is applying for)
- CPC or HCS-D certification-two years of coding experience required
RHIA certification- no ex
Degrees, Licensure, and/or Certification:
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
Knowledge, Skills, and Abilities:
Advanced ICD-10-CM, ICD-10-PCS&/or 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
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
