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Medical Records Coder II
Duke Careers. Review complex medical records and accurately code primary and secondary diagnoses and procedures using ICD-10-CM and CPT/CPT-4 conventions .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates advanced knowledge of ICD-10-CM and CPT-4 coding conventions, along with a thorough understanding of medical record practices and regulations. Capable of effectively communicating with healthcare professionals and coordinating coding activities to ensure optimal reimbursement.
Highest-signal resume keywords
ICD-10-CM CodingCPT-4 CodingDRG/APC Reimbursement KnowledgeRHIA/RHIT/CCS/CPC/HCS-D CertificationMedical Terminology Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Record CodingData EntryCoding Guidelines SequencingAuditing SkillsAnatomy KnowledgePhysiology KnowledgeDisease Process UnderstandingSurgical Techniques KnowledgeCoding Software FamiliarityContinuing Education Development
Soft Skills
Effective CommunicationTeam CoordinationEducational Presentation Skills
Certifications & Qualifications
RHIARHITCCSCPCHCS-D
Industry Keywords
Medical Record PracticesJCAHO StandardsHCFA RegulationsMRNC RequirementsReimbursement Optimization
About the role
Key responsibilities & impact- Review complex medical records and accurately code primary and secondary diagnoses and procedures using ICD-10-CM and CPT/CPT-4 conventions
- Sequence diagnoses and procedures using coding guidelines
- Ensure accurate DRG/APC assignment
- Abstract and compile medical-record data for optimal reimbursement of hospital or professional charges
- Coordinate and review the work of designated employees
- Conduct regular audits to ensure work quality and quantity
- Assist with research, development, and presentation of continuing education programs
- Consult with and educate physicians on coding practices and conventions
- Communicate with nursing and ancillary services personnel to obtain needed documentation
- Maintain knowledge of anatomy, physiology, medical terminology, disease processes, surgical techniques, and coding guidelines through continuing education
- Maintain knowledge of medical-record practices, standards, regulations, JCAHO, HCFA, and MRNC requirements
- Assist with special projects and perform related duties
Requirements
What you’ll need- High school diploma required
- Must hold one active/current certification: RHIA, RHIT, CCS, CPC, or HCS-D
- 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 knowledge of ICD-10-CM and CPT-4 coding conventions
- Knowledge of anatomy and physiology
- Knowledge of medical terminology
- Extensive DRG/APC reimbursement knowledge
- Familiarity with coding software
- Effective written and verbal communication skills
- Data entry/CRT skills
- Thorough understanding of medical record practices, standards, and regulations
- Must reside in one of the specified states: North Carolina, Alabama, Arizona, Connecticut, District of Columbia, Florida, Georgia, Illinois, Iowa, Kentucky, Louisiana, Maine, Michigan, Missouri, Montana, New Hampshire, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, or Washington
Benefits
Comp & perks- $10,000 sign-on bonus paid in 4 equal installments over 24 months
- 100% remote work arrangement
- Continuing education programs
- Training and professional development opportunities
- Equal employment opportunity and inclusive workplace environment
- Reasonable accommodation available upon request