MEDICAL RECORDS CODER II (Outpatient)

Summary

The Medical Records Coder II is a certified coder responsible for coordinating/reviewing the work of subordinate employees and assisting with training and continuing education programs. Key responsibilities include:

• Code medical records utilizing ICD-10-CM and CPT-4 coding conventions.
• Review the medical record to ensure specificity of diagnoses, procedures, and appropriate/optimal reimbursement for hospital and/or professional charges.
• Abstract information from medical records following established methods and procedures.
• Work with physicians on coding practices and conventions 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.
• Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), etc.
• Perform other related duties incidental to the work described herein.

Knowledge, Skills and Abilities

• 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

Qualifications

• Education: High school diploma required.
• Experience:
  • 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
• Certifications: 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).