MEDICAL RECORDS CODER II

Duke Health Integrated Practice is an exceptional, multi-specialty physician practice encompassing 140 clinics across North Carolina. We attract and retain premier medical professionals with competitive compensation, benefits, and a nurturing work atmosphere that unites passion and purpose.

Learn more about us: https://dhip.dukehealth.org/about-us

JOB LOCATION

Central Carolina Surgery - 1002 N Church St, Greensboro, NC 

JOB SUMMARY

Medical Records Coder II is a certified coder. Code medical records utilizing ICD-10 and CPT coding guidelines. Review the medical records to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for professional charges both office and hospital based. Abstract information from medical records following established methods and procedures.

JOB DUTIES AND RESPONSIBILITIES

• Review medical records documentation and accurately code procedures and primary/secondary diagnoses. Sequence the diagnoses and procedures using coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for professional charges. Reviews CCI Edits, LCD and NCD coverage guidelines
• Review the complex medical records (problematic coding that needs research and reference checking) and accurately code the procedure and primary/secondary diagnosis. Reviews CCI Edits, LCD and NCD coverage guidelines
• Consult and educate physicians on coding practices and conventions in order to provide detailed coding information and documentation requirements.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes through continuing education
• Maintain a thorough understanding of medical record practices, standards, regulations, JCAHO, HCFA, and MRNC.
• Assist with special projects and perform other related duties incidental to daily position requirements

JOB ELIGIBILITY REQUIREMENTS

• 
  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

• 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

Some roles within our organization may encompass essential job functions requiring distinct physical and/or mental capabilities. Further details and accommodation requests will be addressed by individual hiring departments.

Duke Health Integrated Practice is dedicated to Equal Opportunity Employment, fostering a diverse workforce without regard to age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

We aspire to build a community grounded in collaboration, innovation, creativity, and belonging. Our shared achievements rely on a dynamic exchange of ideas, flourishing best when a multitude of perspectives, backgrounds, and experiences thrive. Upholding these values is a collective responsibility within our community.

This job description aims to outline representative responsibilities for this title, not an exhaustive account of specific duties. Employees may be assigned job-related tasks beyond those explicitly outlined here.