MEDICAL RECORDS CODER II

Duke Careers
 Durham, NC

PRMO:, established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke PrimaryCare. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Dukes reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.

Occupational Summary

The Medical Records Coder II is a certified Coder . Coordinate/review thework of subordinate employees and assist with the training andcontinuing education programs. Code medical records utilizing ICD-9-CMand CPT-4 coding conventions. Review the medical record to as surespecificity of diagnoses, procedures and appropriate/optimalreimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures.

Work Performed

Review the complex (problematic coding that need s research and referencechecking) medical records and accurately code th e primary/secondarydiagnoses and procedures using ICD-9-CM and/or CPT coding conventions. Coordinate/review the work of designated employees. Ensure quality andquantity 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 a nd compiled ata from medical recordsfor 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 under standing 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.

Knowledge, Skills and Abilities

  • Advanced ICD-9-CM &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

Minimum Qualifications

Education

High school diploma required.

Experience

  • 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, Licensures, Certifications

Must hold one of the following active/current certifications:

  • Registered Health InformationAdministrator (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)

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.

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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.

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