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Medical Records Coder II-Commitment Bonus

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke Health's Patient Revenue Management Organization

Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions.

The HIM Coder II utilizes experience, education, coding guidelines, and Duke coding policies and procedures to perform all daily duties. Performs evaluation and review of medical record documentation to accurately assign codes for primary and secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT-4, and HCPCS Level II.

Sequences diagnoses and procedures according to coding guidelines and ensures DRG or APC assignment is accurate. HIM Coder Tech II focuses on capturing data while considering regulations and requirements to support medical necessity and reimbursement.

Duties and Responsibilities of this Level :

Review medical record documentation and accurately assign codes for primary and secondary diagnoses and procedures using ICD-10-CM, CPT-4, and HCPCS Level II. Sequence diagnoses and procedures with coding guidelines. (54% of the time spent)

Maintain competency in ICD-10-CM, CPT-4, and HCPCS Level II, and stay updated on reimbursement reporting requirements. Maintain a minimum of 95% quality.

Maintain a thorough understanding of anatomy and physiology, medical terminology, pharmacology, disease processes, and surgical techniques through ongoing education programs to effectively apply ICD-10-CM coding guidelines for outpatient diagnoses and CPT-4 and HCPCS Level II for procedures.

Knowledge of coding and charging requirements is essential to ensure accurate submissions, managing edits and denials, and processing claim edits. (4% of time spent)

Research and resolve denied claims for correction and resubmission. (5% of time spent)

Process inpatient conversions from inpatient status to observation, which can take up to 20% of the time.

Understand UHDDS definitions and data requirements to support accurate coding and data collection. Assign and validate the correct discharge disposition based on UHDDS guidelines. (2% of time spent)

Be familiar with NCD / LCD edits to ensure compliance with medical necessity requirements.

Apply knowledge of all coding reference materials and ongoing education to resolve complex or new cases, leading to appropriate diagnosis and procedure code assignments, and validate applicable hard-coded CPT codes. (5% of time spent)

Use logic and reasoning to critically assign diagnosis and procedure codes, considering reimbursement, quality, and data collection needs. (5% of time spent)

Identify cases requiring physician queries when code assignments are unclear or documentation is inadequate or ambiguous. (5% of time spent)

Maintain compliance with quality and quantity standards as specified in hospital coding policies. Follow the Standards of Ethical Coding set by the American Health Information Management Association and adhere to official coding guidelines.

Perform other related duties as needed.

Minimum Qualifications :

Duke is an Equal Opportunity Employer committed to providing equal employment opportunities regardless of age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and related conditions), sexual orientation, or military status.

Duke aims to foster a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on diverse perspectives and experiences. All community members are responsible for maintaining a respectful, welcoming environment where all voices are heard.

Essential Physical Job Functions : Certain roles may include specific physical and / or mental requirements. Additional accommodations will be addressed by each hiring department.

Education : High school diploma required.

Experience : No experience required for RHIA certification; no experience for RHIT certification; one year of coding experience required for certification; two years of coding experience required for CPC or HCS-D certification.

Degrees, Licenses, Certifications : Must hold an active / current certification such as RHIA, RHIT, CCS, CPC, HCS-D, or Home Care Coding.