Medical Records Coder II
Listed on 2026-01-13
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Healthcare
Medical Billing and Coding, Healthcare Administration, Medical Records
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 OrganizationPursue 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.
Duties and Responsibilities of this LevelReview medical record documentation and accurately assign codes for the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT-4-4
-4, and HCPCS Level II. Sequenced diagnoses and procedures using coding guidelines. 80% of the time spent
Maintain competency in ICD-10-CM, ICD-10-PCS, CPT-4 4 and HCPCS Level II, and knowledge of reimbursement reporting requirements.
Maintain a thorough understanding of anatomy and physiology, medical terminology, pharmacology, disease processes, and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM coding guidelines for assignment of outpatient diagnoses and CPT-4 and HCPCS Level II for procedures.
Knowledge of coding and charging requirements to ensure accurate code submission, along with management of edits and denials.
Knowledge of UHDDS definitions and data requirements to support accurate coding and data collection.
Knowledge of NCD/LCD edits to support compliance with medical necessity requirements.
Apply knowledge of all coding reference materials and education to problem-solve unique or new cases, resulting in the assignment of appropriate diagnosis and procedure codes. 5% of time spent
Use logic and reasoning to demonstrate critical thinking in the assignment of diagnosis and procedure codes with consideration for reimbursement, quality, and other data capture requirements.
10% of the time spent
Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. 5% of time spent.
Abide by the Standards of Ethical Coding with quality and quantity standards as outlined in DUHS HIM Coding Policies set forth by the American Health Information Management Association, and adhere to official coding guidelines.
Perform other related duties incidental to the work described herein.
Minimum QualificationsDuke is an Equal Opportunity Employer committed to providing employment opportunities 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.
Essential Physical Job FunctionsCertain 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.
EducationHigh school diploma required.
Experience- 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), Home Care Coding Specialist-Diagnosis (HCS-D), Home Care Coding
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All members of our community have a responsibility to uphold these values.
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