Full-Time

Medical Records Coder 2

Duke University

Duke University

No salary listed

Durham, NC, USA

Remote

Category
Medical, Clinical & Veterinary (1)
Requirements
  • High school diploma required.
Responsibilities
  • Review the complex medical records and accurately code the primary and secondary diagnoses and procedures using ICD-10-CM and CPT coding conventions.
  • Coordinate and review the work of designated employees.
  • Ensure quality and quantity of work 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 and secondary diagnoses and procedures using ICD-10-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 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 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, Health Care Financing Administration, Medical Review of North Carolina, etc.
  • Assist with special projects as required.
  • Perform other related duties incidental to the work described herein.

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