MEDICAL RECORDS CODER I

As a part of Duke Health’s outpatient clinic network, you will enjoy competitive compensation, comprehensive benefits plans, convenient work hours, and many opportunities for career advancement. Become a part of a team that values and invests in you.

JOB LOCATION

This position is remote but may be requested to be available to be onsite on an as-needed basis.

JOB SUMMARY

This position is responsible for coding Anesthesiology physician charges from the operative reports in the Epic system. Reviews records to verify the providers effectively document services rendered as well as properly attesting to their services. Select appropriate ASA and CPT codes based upon best coding standards as established by the AMA. Identifies and helps resolve billing issues within the department. Work Work Queue edits. Identifies Anesthesiology charging and documentation issues and relates these to the appropriate faculty or Revenue Manager.

JOB DUTIES AND RESPONSIBILITIES

• Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the procedures from the operative reports using CPT coding conventions. Documents additions and corrects errors on the Epic encounter according to departmental standards. Communicates with faculty about necessary documentation for accurate charging and billing. Assists faculty on the charging practices and documentation standards for the department and responds to provider inquiries as needed.
• Documents additions and corrects errors on the Epic encounter according to departmental standards. Communicates with faculty about necessary documentation for accurate charging and billing. Assists faculty on the charging practices and documentation standards for the department and responds to provider inquiries as needed.
• Processes the daily Anesthesia charge batches in a timely fashion and reviews patient charts for completeness while verifying that all information is accurately documented and that all appropriate charges are captured.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply CPT coding guidelines to inpatient and outpatient procedures.
• Maintains an understanding of medical record practices, standards, and regulations. Maintain Production and Quality standards set forth by the department. Assist in developing current written policies, procedures, and guidelines.
• Perform other related duties incidental to the work described herein.

JOB ELIGIBILITY REQUIREMENTS

• High school diploma is required. In addition, coursework in Medical Terminology, Anatomy and Physiology, with training in medical records coding is required.

• Requires one year of medical records coding experience related to patient records using ICD-9-CM and the CPT-4 coding systems.

• A medical records coding certification (see below) or degree in Health Information Management or a related field can substitute for the one year experience requirement.

• An active/current certification in one of the following areas is preferred, and will substitute for the one year experience requirement:
  • Certified Coding Associate (CCA)
  • Certified Coding Specialist (CCS) Hospital Coding
  • Certified Professional Coder (CPC)
  • Certified Professional Coder Apprentice (CPC-A)
  • Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
  • Certified Professional Coder Hospital (CPC-H)
• Preferred experience to include: anesthesia coders with some anesthesia background plus a certification

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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.