Medical Records Coder, Trainee
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.
- 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.
Perform other related duties incidental to the work described herein.
Knowledge Skills and Abilities
- ICD-9-CM & CPT-4 coding conventions
- Anatomy and Physiology
- Medical Terminology
- DRG/APC reimbursement
- Coding software familiarity
- Effective written and verbal communication skills
- Data entry/CRT
Duke Entity PRMO
Job Family Level D2
Full Time / Part Time FULL TIME
Regular / Temporary Regular
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 is required. In addition, coursework in Medical Terminology, Anatomy and Physiology, with training in medical records coding is required.
Requires one year of medical records coding experience related to patient records using ICD-9-CM and the CPT-4 coding systems. A medical records coding certification (see below) or degree in Health Information Management or a related field can substitute for the one year experience requirement.
Degrees, Licensures, Certifications
An active/current certification in one of the following areas is preferred, and will substitute for the one year experience requirement: Certified Coding Associate (CCA) Certified Coding Specialist (CCS) Hospital Coding Certified Professional Coder (CPC) Certified Professional Coder Apprentice (CPC-A) Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding Certified Professional Coder Hospital (CPC-H)