Medical Records Coder
The Medical Records Coder II is a certified Coder. Coordinate/review the procedures. 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 record to ass record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital hospital and/ hospital and/or professional charges. Abstract information from medical records following establi established m established methods and Work Performed Review the complex (problematic coding that needs research and reference Perform other related duties incidental to the work described herein. and procedures. checking) 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 em employees. Ensure quality and quantity of work performed through regular audits. Assist with research, development and presentation of continuing education programs on areas of s specialization. Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions. Sequence the diagnoses and pr procedures using coding guidelines. Ensure DRG/APC assignment is accurate. Abstract and co compile data from medical records for appropriate optimal reimbursement for hospital and/or pr professional charges. Consult with and educate physicians on coding practices and conventions in order to provide d detailed coding information. Communicate with nursing and ancillary services personnel for n 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- 10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses Maint Maint Maintain a thorough understanding of medical record practices, standards, regulations, Joint Comm Commi Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Admin Administration (HCFA), Medical Review of North Carolina (MRNC), etc. Assist with special projects as as required.
Knowledge, Skills and Abilities
Advanced ICD-9-CM & CPT-4 coding conventions Effective written and verbal communication skills Anatomy and Physiology Medical Terminology Extensive DRG/APC reimbursement knowledge Coding software familiarity Data entry/CRT
Level Characteristics N/A
Duke Entity PRMO
Job Family Level E2
Full Time / Part Time FULL TIME
Regular / Temporary Regular
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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.
Experience and Licensure\\Certification
Prefer candidates have coding specific.experience with the Pediatric Intensive Care Unit and Intensive Care Neonatal Nursery. Pediatric coding experience in general considered.
CPC required with two years minimum of coding experience required. CPEDC (certified peds) a plus.