Medical Records Coder Ii

Job Title

Medical Records Coder II at Duke University Health System

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.

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.

• Review complex 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.
• Sequence diagnoses and procedures using coding guidelines and 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 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.
• 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 and perform other related duties incidental to the work described herein.

• 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.

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Certain jobs at Duke University and Duke University Health System may include essential job 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.

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

• 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
• Homecare Coding Specialist-Diagnosis (HCS-D) - Homecare Coding