Medical Record Coder

North Carolina, United Sates
26 Nov 2018
End of advertisement period
26 Jan 2019
Contract Type
Full Time

Job Description

Duties and Responsibilities of this Level:

Review medical record documentation and accurately assign codes for the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT-4 and HCPCS Level II. Sequence diagnoses and procedures using coding guidelines. 80% of time spent

Maintain competency in ICD-10-CM, ICD-10-PCS, CPT-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 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 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.

Maintain compliance with quality and quantity standards as outlined in DUHS HIM Coding Policies. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.

Perform other related duties incidental to the work described herein.

Requisition Number: 401512812
Location: Durham 
Duke Entity: PRMO
Job Family Level: E2
Exempt/Non-Exempt: Non-exempt 
Full Time / Part Time: FULL TIME
Regular / Temporary: Regular 
Shift: First/Day

Minimum Qualifications

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/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.


High school diploma required.


2 or more years of coding experience highly preferred. 

Degrees, Licensures, Certifications

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) or AHIMA

Auto req: ID106427BR