MEDICAL RECORDS CODER II - PROFESSIONAL CODING
General Description of the Job Class
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-9-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.
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-9-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.
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-9-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- 9-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.
Professional Coding experience.
Academic medical center experience.
Computer Assisted Coding experience.
Duke University is an Affirmative Action/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, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas?an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/o rmental 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 requiredRHIT certification- no experience requiredCCS certification- one year of coding experience requiredCPC or HCS-D certification- two years of coding experience required
Degrees, Licensures, Certifications
Must hold one of the following active/current certifications:Registered Health Information Administrator (RHIA) Hospital CodingRegistered Health Information Technician (RHIT) Hospital CodingCertified Coding Specialist (CCS) Hospital CodingCertified Professional Coder (CPC)Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
Preference for CodeRyte, 3M and Interventional experience
Radiology Professional Coding experience. GI Professional Coding experience. Academic medical center experience. Computer Assisted Coding experience (CodeRyte, 3M, etc.)