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MEDICAL RECORDS CODER II
Job Title: MEDICAL RECORDS CODER II
Job Code: 4097
Job Level: E2
Revised Date: 12/06/2011
Supervisory Responsibility: No
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.
Assist with special projects as required.
Perform other related duties incidental to the work described herein.
Required Qualifications at this Level
High school diploma required.
RHIA certification- no experience required
RHIT certification- no experience required
CCS certification- one year of coding experience required
CPC or HCS-D certification- two years of coding experience required
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-9-CM & CPT-4 coding conventions
Anatomy and Physiology
Extensive DRG/APC reimbursement knowledge
Coding software familiarity
Effective written and verbal communication skills
Distinguishing Characteristics of this Level
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
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.