Medical Records Coder II

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Analyze intricate medical records that require research and reference verification to accurately code primary and secondary diagnoses and procedures in accordance with ICD-10-CM coding standards.

• Examine medical record documentation to correctly code primary and secondary diagnoses using ICD-10-CM coding standards.

• Organize diagnoses in accordance with established coding guidelines.

• Extract and compile data from medical records to ensure optimal reimbursement for Home Health or Hospice services and/or professional charges.

• Collaborate with and educate physicians on coding practices and standards to provide comprehensive coding information.

• Coordinate with nursing and ancillary services staff to gather necessary documentation for precise coding.

• Maintain a comprehensive understanding of anatomy, physiology, medical terminology, disease processes, and surgical techniques by engaging in continuing education programs to effectively implement ICD-10-CM coding guidelines for both inpatient and outpatient diagnoses and procedures.

• Keep abreast of medical record practices, standards, regulations, and guidelines from The Joint Commission, Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), DHHS (Department of Health and Human Services), etc.

• Support special projects as needed.

• Execute other related responsibilities as assigned.

⛳️ Requirements

• High School Diploma is mandatory.

• RHIA certification is required, no prior experience necessary.

• RHIT certification is required, no prior experience necessary.

• CCS certification requires one year of coding experience.

• CPC or HCS-D certification necessitates two years of coding experience.

• Candidates must possess one of the following active/current certifications: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Homecare Coding Specialist-Diagnosis (HCS-D).

• Advanced knowledge of ICD-10-CM & CPT-4 coding conventions.

• Proficiency in Anatomy and Physiology.

• Strong understanding of Medical Terminology.

• In-depth knowledge of DRG/APC reimbursement.

• Familiarity with HH PDGM related to coding.

• Competence in using coding software.

• Strong written and verbal communication abilities.

• Proficient in data entry/CRT.

🏝️ Benefits

• Must reside within 2 hours of the office.

• All Duke medical coding positions require candidates to possess a North Carolina address as a condition of employment.