Medical Records Coder II – Ophthalmology

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Duke Careers

10,000+ employees

Founded 1924

📚 Education

🤝 Non-profit

🌍 Social Impact

Education • Non-profit • Social Impact

Duke Careers is a platform connected to Duke University's rich legacy, established in 1924. It aims to celebrate the centennial of Duke University while providing resources, stories, and interviews that reflect the university's history, current achievements, and future aspirations. A key focus of Duke Careers is to engage with alumni and the community, showcasing the transformative impact of education and leadership within the university.

📋 Description

• Coordinate/review the work of subordinate employees and assist with the training and continuing education programs. • Code medical records utilizing ICD-10-CM and CPT-4 coding conventions. • Review the medical record to ensure specificity of diagnoses, procedures, and appropriate/optimal reimbursement for hospital and/or professional charges. • Abstract information from medical records following established methods and procedures. • 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 and/or CPT coding conventions. • Ensure quality and quantity of work performed through regular audits. • Assist with research, development, and presentation of continuing education programs in areas of specialization. • 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 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.

🎯 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 • Advanced ICD-10-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 Level Characteristics N/A

🏖️ Benefits

• Now offering a $10,000 sign-on bonus that will pay out in 4 equal installments over 24 months—6-month increments.

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