MEDICAL RECORDS CODER II (Emergency Medicine)

Summary

The Medical Records Coder II is a certified coder responsible for coordinating/reviewing the work of subordinate employees, assisting with training and continuing education programs, and ensuring accuracy in coding medical records using ICD-10-CM and CPT coding conventions.

Responsibilities

• Cover complex medical records needing research and reference checking
• Code medical records utilizing ICD-10-CM and CPT coding conventions
• Review medical records to ensure specificity of diagnoses, procedures, and appropriate/optimal reimbursement
• Abstract information from medical records following established methods and procedures
• Ensure quality and quantity of work performed through regular audits
• Absorb and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges
• 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
• Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information
• Perform other related duties incidental to the work described herein

Requirements

• 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

Skills and Abilities

• Knowledge of medical record practices, standards, regulations, the Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), etc.
• Ability to maintain a thorough understanding of coding guidelines and sequence diagnoses and procedures
• Ability to abstract and compile data from medical records for appropriate optimal reimbursement
• Ability to communicate with nursing and ancillary services personnel for needed documentation for accurate coding

Qualifications

• High school diploma required
• One year of coding experience required for CCS certification
• Two years of coding experience required for CPC or HCS-D certification
• Must hold one of the following active/current certifications: Registered Health Information Administrator (RHIA), Hospital Coding Registered Health Information Technician (RHIT), Hospital Coding Certified Coding Specialist (CCS), Hospital Coding Certified Professional Coder (CPC), Homecare Coding Specialist-Diagnosis (HCS-D)