Medical Records Coder- Inpatient

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Medical Records Coder II-Inpatient

General Description of the Job Class

The Medical Records Coder II (Inpatient) 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-10-CM, ICD-10-PCS and/or 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-10-CM, ICD-10-PCS 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-10-CM, ICD-10-PCS and/or 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-10-CM, ICD-10-PCS and/or 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.

Assist with special projects as required.

Perform other related duties incidental to the work described herein.

Required Qualifications at this Level

Education:

High school diploma required.

Experience:

• RHIA certification-no experience required
• RHIT certification-no experience required
• CCS certification-Two years of coding experience required (Must be in the service applicant is applying for)
• CPC or HCS-D certification-two years of coding experience required

RHIA certification- no ex

Degrees, Licensure, and/or Certification

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)
• Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding

Knowledge, Skills, and Abilities:

Advanced ICD-10-CM, ICD-10-PCS&/or CPT-4 coding conventions

Anatomy and Physiology

Medical Terminology

Extensive DRG/APC reimbursement knowledge

Coding software familiarity

Effective written and verbal communication skills

Data entry/CRT

Duke 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.

Job Type: Full-time

Work Location: In person