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Medical Records Coder II

2 months ago

Durham NC United States Duke Health Full time

Duke Homecare & Hospice Duke Homecare & Hospice offers hospice, home health and infusion services as well as serves as the home for the Duke Caregiver Support Program. Our Hospice team works closely with a patient's physician to provide comprehensive, individualized care in the comfort their home or at our inpatient hospice facility located in Durham. Our team of nurses, therapists, social workers, counselors, and chaplains help patients and their families manage advanced medical conditions. Duke Home Health provides services in a patient's home that include skilled nursing, physical therapy, occupational therapy, speech therapy, social service, home health aides, and pain and wound management. Our infusion team comes to a patient's home to administer intravenous medications, including antibiotics and chemotherapy, to children and adults. Our nurses, pharmacists, dietitians, and patient services coordinators work under the direction of a patient's doctor to monitor needs and treatment.

 

*Now offering a $5,000 commitment bonus that will pay out in 2 equal installments over 12 months in 6-month increments.

 

 

Must Reside within 2 Hours of Office

 

Please note: All Duke medical coding opportunities require candidates to have a North Carolina address as a condition of employment.

 

Home Health Coder position (Hybrid)
 

The Duke HomeCare & Hospice Medical Records Coder II is a certified Coder, responsible for coding activities for the home health and hospice areas at Duke. Code medical records utilizing ICD-10-CM and CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures. 

 

MAJOR JOB RESPONSIBILITIES


•    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 
•    Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions.
•    Sequence the diagnoses and procedures using coding guidelines. Ensure DRG (Diagnostic Related Grouping) /APC (Medicare’s Ambulatory Payment Classification) assignment is accurate.
•    Abstract and compile data from medical records for appropriate optimal reimbursement for Home Health or Hospice 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, The Joint Commission, Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), DHHS (Department of Health and              Human Service), etc. 
•    Assist with special projects as required. 
•    Perform other related duties incidental to the work described herein. 
 

PREFERRED QUALIFICATIONS 

 

Education and Formal Training

 

High School Diploma required

 

Licensures, Certifications

 

Must hold one of the following active/current certifications:

Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding (Preferred)

Certified Professional Coder (CPC)

Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding

Registered Health Information Administrator (RHIA) Hospital Coding

Registered Health Information Technician (RHIT) Hospital Coding

 

Professional Work Experience 

 

Prior experience in homecare and hospice coding strongly preferred

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

 

Knowledge, Skills & Abilities

 

  • Advanced ICD-10-CM & CPT-4 coding conventions 
  • Anatomy and Physiology 
  • Medical Terminology 
  • Extensive DRG/APC reimbursement knowledge 
  • HH PDGM Knowledge R/T Coding
  • Coding software familiarity 
  • Effective written and verbal communication skills 
  • Data entry/CRT 
     

 

 

 

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

 

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

 

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.