Welcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position. To ensure accurate and appropriate gathering of information into the coding classification systems to meet departmental, hospital and outside agency requirements. This includes ensuring appropriate reimbursement, compliance and charging with the various coding guidelines and regulatory agencies. Responsible for obtaining accurate and complete documentation in the medical record for accurate coding assignment. Responsible for the coding of moderately complex patient classes i.e. ED, observations, same day care, etc.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. High School Diploma or Equivalent.
2. Certification in one of the following: RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator), CCS (Certified Coding Specialist), COC-A (Certified Outpatient Coder-Apprentice), COC (Certified Outpatient Coder), Formerly CPC-H (Certified Professional Coder-Hospital), CPC (Certified Professional Coder) or CIC (Certified Inpatient Coder).
EXPERIENCE:
1. One (1) year of hospital coding experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Graduate of Health Information Technology (HIT) or equivalent program OR Medical Coding Certification Program.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Reviews and accurately interprets medical record documentation from all hospital accounts in order to identify all diagnosis and procedures that affect the current outpatient encounter and assigns the appropriate ICD-10, CPT, or modifier codes for each diagnosis and procedure that is identified. Codes moderately complex patient classes.
2. Assigns hospital codes to a variety of patient classes (i.e. ED, OBS, SDC, etc.).
3. Assures that quality and timely coding, charging and abstraction of accounts are completed daily for assigned specialty areas.
4. Maintains and enhances current levels of coding knowledge through quality review, attendance and participation at clinical in-services and coding seminars, internal meetings, study of circulating reference materials, and inclusion of updates to coding manuals.
5. Assures the accuracy, quality, and timely review of data needed to obtain a clean bill.
6. Contacts physicians or any persons necessary to obtain information required for to accurately code assignments. Works and communicates with other offices in any manner necessary to facilitate the billing process.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Must be able to sit for long periods of time.
2. Must have visual and hearing acuity within the normal range.
3. Must have manual dexterity needed to operate computer and office equipment.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
2. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.
3. May require travel.
SKILLS AND ABILITIES:
1. Must be able to concentrate and maintain accuracy during constant interruptions.
2. Must possess independent decision-making ability.
3. Must possess the ability to prioritize job duties.
4. Must be able to handle high stress situations.
5. Must be able to adapt to changes in the workplace.
6. Must be able to organize and complete assigned tasks.
7. Must possess excellent written and verbal communication skills.
8. Must possess the knowledge of anatomy, physiology and medical terminology.
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Exempt/Non-Exempt:
United States of America (Non-Exempt)
Company:
SYSTEM West Virginia University Health System
Cost Center:
548 SYSTEM HIM Coding Analysis
Summary: Promotes a professional patient-centered practice image by efficiently performing a variety of business and clerical tasks. Responsible for quality review of physician coding and charging to facilitate billing accuracy. Serves as billing and coding resource for assigned practice. Provides coding feedback and education to practice staff and providers as necessary and requested. Serves as a liaison between physician practices and Central Billing Office for billing issues. Utilize team-based approach to all tasks.
Required Education: High School diploma or equivalent. Certified Coder - RHIT or CPC or actively pursuing to obtain
Required Experience: Two or more years healthcare experience in a physician practice or healthcare facility setting. Extensive knowledge of ICD-10 and CPT codes. Extensive knowledge of all third-party payers: Medicare, Medicaid and Worker's Compensation and Managed Care. Given training and on-the-job experience, incumbent should be proficient in the basic aspects of the position within three months of employment date.
$44k-50k yearly est. Auto-Apply 33d ago
Senior Medical Coder
Biodata Partners
Medical coder job in Raleigh, NC
Perform dictionary coding in accordance with study specific coding conventions using MedDRA and WHO Drug within various coding systems. Manage end-to-end delivery of clinical data management coding responsibilities concurrently for single/multiple projects ensuring quality and timeliness. Provide leadership and mentorship to Medical Coding Specialists as needed. Create, review, and maintain guidance and training documentation for coding guidelines an accordance with ICH guidance, official coding guidelines and dictionary definitions
Responsibilities:
Perform coding in accordance with study specific coding conventions as outlined in the Data Management Plan (DMP)
Perform coding using MedDRA and WHO Drug of (eCRF) verbatim terms using various coding systems
Provide independent review of coded data by ensuring consistent code assignment within a project by reviewing coding and re-assignment
Responsible for medical coding review, synonym dictionaries review, therapeutically aligned coding conventions
Create, review, and maintain guidance and training documentation for coding guidelines an accordance with ICH guidance, official coding guidelines and dictionary definitions
Provide support to other departments concerning dictionary use and code assignment
Ensure compliance with industry quality standards, regulations, guidelines and procedures
Management of query assignment within eCRF systems for questionable verbatim terms
Preparation of specific study coding reports for accuracy and consistency as well as client requirements
Interaction with clients regarding specific coding requests and coding timelines
Participate in system upgrades, including User Acceptance Testing (UAT) to maintain a validated coding environment
Perform coding related study close activities ensuring all coding is accurate and proper documentation is complete
Liaise with Clinical Data Managers and Programmers for purposes of project requirements
Communicate issues that require decisions, including proposal for a solution
CTCAE coding and review
Experience:
5+ years in Pharmaceutical/Biotechnology industry or CRO environment
Thorough knowledge and experience with WHODrug AND MedDRA dictionaries
Knowledge of ICH/GCP guidelines, 21 CFR Part 11 and clinical trial methodology
Excellent verbal and written communication skills
Detail oriented, ability to multitask with strong prioritization, planning and organization skills
Excellent team player
Proficiency in Microsoft Office Applications
Working knowledge of MedDRA and WHODrug best practice documents
Good understanding of Clinical Data Management processes and the applicable regulatory requirements
Good overview of all systems lined to the coding process, and understanding of their interactions and dependencies
Education:
Bachelor of Science degree in biology or health-related field preferred
Language Skills Required:
Speaking: English (Required)
Writing/Reading: English (Required)
$44k-64k yearly est. 60d+ ago
Entry -Level Medical Coder
Revel Staffing
Medical coder job in Raleigh, NC
A confidential healthcare organization in Raleigh is seeking a motivated Entry -Level MedicalCoder / Billing Assistant to join their administrative team. This position offers a great pathway into the healthcare field for individuals interested in medical billing and coding.
Key Responsibilities
Code medical procedures accurately for billing and insurance claims.
Prepare financial reports and submit claims to insurance companies or patients.
Enter and maintain patient data in administrative and billing systems.
Track outstanding claims and follow up on unpaid accounts.
Communicate with patients to discuss balances and develop payment plans.
Maintain confidentiality and comply with HIPAA and all healthcare regulations.
Qualifications
High school diploma or equivalent required; healthcare coursework a plus.
MediClear or equivalent compliance credential required.
Strong communication, organization, and time -management skills.
Ability to remain professional and calm while working with patients and insurance representatives.
Basic computer proficiency and familiarity with billing software or EMR systems preferred.
Why Join Us
Excellent opportunity for those starting a career in healthcare administration.
Supportive, team -oriented work environment.
Comprehensive benefits and advancement potential within a growing healthcare organization.
$44k-64k yearly est. 52d ago
Inpatient Facility Coder
The Nemours Foundation
Medical coder job in Wilmington, NC
Nemours is seeking a Coder! This position is responsible for the proper coding and abstracting of inpatient facility medical records using ICD-10-CM diagnosis and PCS codes in accordance with ICD 10 CM and PCS coding conventions and the Official Guidelines for Coding and Reporting.
Knowledge and adherence to the Official Coding Guidelines for ICD 10 CM and PCS is required. Participation in on-going coding training and education is essential and required for this position. Maintaining annual coding certification through the American Health Information Management Association (AHIMA) or the AAPC is also required.
Responsibilities:
Translate diagnostic and procedural documentation into the appropriate ICD-10-CM, PCS, SOI, and ROM assignments
Select the appropriate principal diagnosis code, secondary diagnoses, and procedure codes according to the UHDDS.
Analyze the circumstances of admission to ensure proper sequencing, selection of discharge disposition, and Present on Admission (POA) assignment.
Appropriate capture Complications and Comorbidities.
Ensure appropriate DRG assignment.
Identify cases that require further clarification based on the clinical indicators in the record.
Communicate and work with the Clinical Documentation Specialist.
Review medical record information using Epic.
Abstract records in an accurate manner according to established procedures and guidelines.
Meet and/or exceed coding quality and productivity standards.
Review and address coding validation edits, 3M edits, and participate in Coding Prebill reviews as well as peer reviews.
Demonstrate and incorporate a working knowledge of the Epic system for retrieval of clinical data for coding purposes.
Assist with coding shadowing and cross training as needed.
Qualifications:
High School Diploma required; Associate Degree is preferred.
Certified Coding Specialist Certification (CCS), Certified Inpatient Coder (CIC), or CPC is required.
Minimum one year coding experience is required.
Knowledge of the Official Coding Guidelines for ICD 10 CM and PCS is required.
Previous experience with All Patient Refined (APR) Diagnostic Related Groups (DRGs) is preferred.
Pediatric inpatient coding experience is preferred.
$43k-63k yearly est. Auto-Apply 60d+ ago
RCM Coder
Atlantic Medical Management 4.2
Medical coder job in Jacksonville, NC
Atlantic Medical Management is currently hiring for professional Medical Coding Specialist who is goal oriented, revenue driven, highly accurate and motivated. This position includes collecting reimbursements by gathering, coding, and transmitting patient care information; resolving discrepancies; adjusting patient bills; working AR and preparing reports. Must have ProFee coding and billing experience. This is a remote position and candidates must be located in North Carolina.
Essential Functions
Post medical charges into NextGen software in a timely manner to meet daily and monthly goals.
Reviews and verifies documentation supports diagnoses, procedures, and treatment results.
Identifies diagnostic and procedural information and assigns codes for reimbursements
Ability to navigate around CPT, ICD-10, and HCPCS.
Work with providers to correct the diagnosis or procedure codes so that the claim can be processed.
Identify coding or billing problems from EOBs and work to correct the errors in a timely manner
Maintain in depth knowledge of all payers.
Coordinate with clinics to ensure all outstanding superbills are collected prior to month end close.
Update patient demographic and insurance
Transfer open balances to correct insurance
Work with patients and guarantors to secure payment
Resolves disputed claims by gathering, verifying, and providing additional information
Identify problem accounts and escalate as appropriate.
Write appeals and include supporting documentation
Run appropriate reports and contact insurance companies to resolve unpaid claims
Meet set department metrics and threshold set forth by manager.
Assist with special projects and other job-related duties as needed.
Minimum Qualifications
High School Diploma.
2 years of Professional coding/billing experience
AAPC certification preferred
Experience Medicare, Medicaid and other commercial and private payers.
Demonstrated well-developed interpersonal skills to interact in sensitive and/or complex situation with a variety of people.
Excellent customer service and professionalism.
Maintains patient confidentiality.
Proficient computer skills.
Organized and efficient.
Self-motivated to meet objectives
Benefits:
401(k)
Health, Dental and Vision insurance
Employee assistance program
AFLAC
Paid time off
$55k-68k yearly est. 60d+ ago
Coding Specialist
Deerfield Management Companies 4.4
Medical coder job in Durham, NC
Exciting Career Opportunity with Avance Care!
Join our rapidly expanding network of 37 practice locations in the Triangle Area (Raleigh-Durham-Chapel Hill), the Charlotte Region, and Wilmington, NC.
Avance Care is dedicated to elevating the standard of healthcare. As one of North Carolina's largest networks of independent primary care practices, we offer comprehensive services to support the physical, mental, and emotional health of our patients.
As a Coding Specialist, you'll support and maintain coding compliance and patient assessments by applying Certified Professional Coding (CPC) principles to claim documentation process, reducing institutional, legal and financial risk.
This is a full-time role involving 8 hours weekday shifts with no weekends schedule.
We operate in a busy, fast-paced environment, and we seek a candidate who thrives under such conditions.
We offer a comprehensive benefits package available on the first of the month following 30 days of employment.
Selected Responsibilities:
Actively abstract and code daily patient encounters through chart documentation, billing for all services, and appropriate assignment of E&M coding related to chart documentation, time, and medical decision making
Thorough understanding of clinic coding (E/M) documentation requirements and HCC concepts impacting population Health Risk Adjustment reimbursement initiatives
Ability to review documentation and abstract all codes with specific emphasis on identifying the most accurate severity of illness according to CMS HCC guidelines
Maintains knowledge regarding policies and procedures with Medicare/Medicaid Carriers and third-party payers, including HCC and RAF guidelines
Effectively work with and support providers through structured communication as it related to chart documentation and coding practices
Understand and apply Correct Coding Initiative (CCI) edits and modifiers, as sometimes specifically required by 3
rd
party payers or Medicare
Assign missing procedure CPT, or HCPCS from the Current Procedure Manual and Common Procedure Coding System Manual when necessary
Candidates should preferably have one of the following certifications: Certified Professional Coder (CPC) required, Certified Professional Coder (CPC-A) preferred, or Certified Risk Adjustment Coder (CRC) highly preferred along with at least one year of E&M Coding experience.
Other Priorities:
Strong verbal and written communication
Knowledge of insurance practices
Knowledge of CPT, HCPCs, and ICD-10 coding
Time management and workload prioritization skills
If you are excited to join a growing organization focused on changing the way healthcare is delivered to patients in North Carolina, please submit your resume.
All offers of employment are contingent upon the successful completion of a background check and drug screen.
Avance Care provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to religion, race, creed, color, sex, sexual orientation, gender identification, alienage or citizenship status, national origin, age, marital status, pregnancy, disability, veteran or military status, predisposing genetic characteristics or any other characteristic protected by applicable federal, state or local law.
$97k-120k yearly est. Auto-Apply 60d+ ago
Medical Coder
Gentiva Hospice
Medical coder job in Mooresville, NC
Drive Accuracy. Support Care Teams. Advance Hospice Outcomes.
We are seeking a dedicated MedicalCoder to join our team, reporting directly to the Billing Manager. In this role, you will conduct precise and compliant coding activities aligned with company policies, ensuring accurate hospice diagnosis coding and supporting our branches with exceptional service.
Key Responsibilities:
Review diagnosis lists to identify actual or potential coding errors.
Recognize and accurately code diagnoses documented within medical records beyond standard diagnosis lists.
Provide expert guidance to branches for correcting coding errors using standardized coding guidelines.
Collaborate effectively with other coders to achieve team goals.
Adhere strictly to company policies, Coding Guidelines, Coding Clinic advisories, and hospice billing regulations.
Maintain the highest professionalism and discretion in all actions.
Demonstrate excellent communication skills via telephone and email with branches and company leadership.
Manage time efficiently, prioritize assignments, and meet daily productivity goals monitored through scorecards and quality assurance metrics.
Contribute to process improvements and documentation enhancements.
About You
Required Skills and Expertise:
Strong knowledge of ICD-10-CM Guidelines for Coding and Reporting and coding conventions.
Proficient in locating and validating diagnosis codes using coding manuals or electronic ICD-10 databases.
Ability to educate and train team members on proper coding guidelines.
Competency in Microsoft Word, Excel, Outlook, and PowerPoint.
Experience with HomeCare HomeBase software is a plus.
Education and Experience:
Preferred: Minimum of four years recent full-time ICD-10-CM coding experience in home health or hospice settings.
Considered: Candidates with two or fewer years of recent full-time ICD-10-CM coding experience in home health or hospice.
Certifications:
Candidates must hold at least one active credential from the following:
HCS-H
HCS-D
BCHH-C
AAPC
We Offer
Benefits for All Associates (Full-Time, Part-Time & Per Diem):
Competitive Pay
401(k) with Company Match
Career Advancement Opportunities
National & Local Recognition Programs
Teammate Assistance Fund
Additional Full-Time Benefits:
Medical, Dental, Vision Insurance
Mileage Reimbursement or Fleet Vehicle Program
Generous Paid Time Off + 7 Paid Holidays
Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care)
Education Support & Tuition Assistance (ASN to BSN, BSN to MSN)
Free Continuing Education Units (CEUs)
Company-paid Life & Long-Term Disability Insurance
Voluntary Benefits (Pet, Critical Illness, Accident, LTC)
Apply today to become part of a team committed to expanding access, building partnerships, and transforming care through expert medical coding.
Legalese
This is a safety-sensitive position
Employee must meet minimum requirements to be eligible for benefits
Where applicable, employee must meet state specific requirements
We are proud to be an EEO employer
We maintain a drug-free workplace
Location Gentiva Hospice Our Company
At Gentiva, it is our privilege to offer compassionate care in the comfort of wherever our patients call home. We are a national leader in hospice care, palliative care, home health care, and advanced illness management, with nearly 600 locations and thousands of dedicated clinicians across 38 states.
Our place is by the side of those who need us - from helping people recover from illness, injury, or surgery in the comfort of their homes to guiding patients and their families through the physical, emotional, and spiritual effects of a serious illness or terminal diagnosis.
Our nationwide reach is powered by a family of trusted brands that include:
Hospice care: Gentiva Hospice, Emerald Coast Hospice Care, Heartland Hospice, Hospice Plus, New Century Hospice, Regency SouthernCare, SouthernCare Hospice Services, SouthernCare New Beacon
Palliative care: Empatia Palliative Care, Emerald Coast Palliative Care
Home health care: Heartland Home Health
Advanced illness management: Illumia Health
With corporate headquarters in Atlanta, Georgia, and providers delivering care across the U.S., we are proud to offer rewarding careers in a collaborative environment where inspiring achievements are recognized - and kindness is celebrated.
$42k-61k yearly est. Auto-Apply 35d ago
Medical Records Coder II-Inpatient
Duke's Fuqua School of Business
Medical coder job in North Carolina
PRMO Established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke Primary Care. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke's reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.
*Now offering a $10,000 sign-on bonus that will pay out in 4 equal installments over 24 months - 6-month increments.
Occ Summary-
The Medical Records Coder II (Inpatient) is a certified Coder. Coordinate/review the work of subordinate employees and assist with the training and continuing education programs. Code medical records utilizing ICD-10-CM, ICD-10-PCS and/or 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.
Duties and Responsibilities of this Level
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, ICD-10-PCS and/or CPT coding conventions.
Coordinate/review the work of designated employees. Ensure quality and quantity of work performed through regular audits.
Assist with research, development and presentation of continuing education programs on areas of specialization.
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS and/or CPT-4 coding conventions. Sequence the diagnoses and procedures using coding guidelines. Ensure DRG/APC assignment is accurate. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital 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, ICD-10-PCS and/or CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
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.
Assist with special projects as required.
Perform other related duties incidental to the work described herein.
Required Qualifications at this Level
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
Degrees, Licensures, Certifications
Must hold one of the following active/current certifications: Registered Health Information Administrator (RHIA) Hospital Coding RegisteredHealth Information Technician (RHIT) Hospital Coding Certified Coding Specialist (CCS) Hospital Coding Certified Professional Coder (CPC) Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
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 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.
$49k-76k yearly est. 60d+ ago
Coder
J Arthur Dosher Memorial Hospital
Medical coder job in Southport, NC
Job DescriptionDescription:
Performs the coding of outpatient and/or inpatient and ancillary medical records as well as various Health Information Management duties.
(not an exhaustive list):
Review medical records classified as inpatient, observation, treatment room, Emergency Department and ancillary
Assign appropriate diagnosis/procedure codes using the ICD-10 and CPT-4 classification systems. Assign codes using coding books or by using the 3M/code finder computer system
Follow established coding guidelines when assigning diagnosis/procedure codes to records
Request diagnosis/procedural information from physician when information is not available at the time of coding
Utilize approved resources for coding purposes, i.e. CMS.gov website
Requirements:
Education:
High School diploma or equivalent
Knowledge of Medical Terminology, Anatomy and Physiology, CPT and/or ICD-10 PCS, and ICD10-CM coding systems
RHIT, RHIA, or professional coding credential required
Experience
Two years coding experience preferred
$43k-62k yearly est. 8d ago
EMR Analyst
Clough, Harbour & Associates, LLP
Medical coder job in Raleigh, NC
Join Us: Finding a better way. At CHA, we believe in the power of clean water, resilient energy, safer roads, and structures that harmoniously blend with their surroundings. We create solutions. We help People. We improve our world. At CHA, we embed ourselves in our communities - and take pride in improving things where we live. At the foundation is a commitment to inclusion and diversity and choosing to treat everyone with dignity and respect. We also take accountability for making decisions that promote sustainability in our business and our designs. We are on a mission to reduce our environmental footprint and bring greener solutions to our clients. We are responsibly creating a more sustainable future in ways that we can all see and touch. Together. Every day.
CHA Consulting, Inc. is currently seeking an EMR Analyst to join our Power & Manufacturing - Asset Management Team at our Raleigh, NC office.
What You'll Do:
The CHA team is always innovating by asking ourselves if there's a better way. Our goal is to leverage technology platforms across the spectrum of new advances to deliver scalable and user-friendly solutions that efficiently manage and interpret critical data - elevating workflow efficiency while boosting user productivity. Our technology solutions span markets and sectors, delivering information and energizing design and management teams - sparking the imagination and optimizing results.
Working independently, the EMR Analyst will lead field walkdowns of client assets in order to produce detailed equipment hierarchy and instrumentation. The professional in this role will extract and maintain data from various cloud-based applications to conduct this data analysis. This includes maintaining Master Asset Listings (MAL) and detailed metrics in support of client projects, as well as attending project team meetings to facilitate the population and entry of asset information into computerized maintenance management systems (CMMS).
The EMR Analyst will provide and facilitate required training for personnel in support of client projects, onboarding and annual trainings, CCMS, compliance reporting, and capital projects. Additionally, this individual will provide guidance and mentorship to junior team members including reviewing technical documentation and spreadsheet updates to ensure accuracy.
At CHA, you can build a career and find your passion across our diverse business lines and project teams. Being part of CHA means being part of a team of talented professionals, where you'll find support for your career growth and the opportunity to impact our industry and our communities. Find your "why" at CHA!
What You Bring:
* High school diploma or equivalent is required; Bachelor's degree preferred
* Minimum of 7 years of related experience required
* Valid driver's license required
* Excellent written and verbal communication skills with a positive and collaborative attitude
* Demonstrates a positive and collaborative attitude
* Proficiency with CMMS softwares such as SAP, BlueMountain, Maximo required
* Proficient in Microsoft Office 365 and cloud-based tools
* Proficient in Microsoft Excel with the ability to manipulate spreadsheets, formulas, etc.
* Proficiency in SharePoint and file management with excellent organizational skills
* Demonstrates a strong willingness to learn and train junior team members
* Knowledge of metrology data management preferred
* Ability to work on multiple projects and detail oriented
* Ability to adhere to client site-specific requirements
* Ability to travel locally as needed
Salary Range:
$33.65 - 42.30
Salary is based on a variety of factors, including, but not limited to, qualifications, experience, education, licenses, specialty, training, and fair market evaluation based on industry standards.
Culture/EEO Statement:
At CHA, we work every day to create solutions, help people, and improve our world, committed to creating and fostering excellence in our diverse and highly talented teams. Our teams continually strive to find better ways - always searching, never settling - to achieve extraordinary results. Our values around hiring, training, and community engagement reflect a company culture that is inclusive and forward leaning, always pushing the limits of what is possible.
We as an organization celebrate the values of inclusion and equality, and advocate for the full participation of all people in an environment free of discrimination. To support these values, we invite all qualified applicants to be considered for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship, age, disability, protected veteran status, or any other characteristic protected by law.
$33.7-42.3 hourly Auto-Apply 60d+ ago
Medical Records Manager
Connected Crew
Medical coder job in Charlotte, NC
Job Description
Join Our Team as a Medical Records Manager!
Are you organized, detail-oriented, and passionate about maintaining accurate records in the healthcare field? Connected Crew, located in Charlotte, NC, is looking for a Medical Records Manager to join our dedicated team. If you have at least one year of experience and a knack for managing information efficiently, this could be the perfect opportunity for you!
About Connected Crew
At Connected Crew, we pride ourselves on being a trusted partner in the healthcare industry. Our mission is to ensure seamless operations and provide top-notch support to our clients and team members. We believe in fostering a collaborative and professional environment where everyone can thrive.
What You'll Do as a Medical Records Manager
As our Medical Records Manager, you'll play a crucial role in ensuring the accuracy, security, and accessibility of medical records. Your responsibilities will include:
Overseeing the organization and maintenance of medical records.
Ensuring compliance with all applicable regulations and standards.
Managing the secure storage and retrieval of sensitive information.
Collaborating with healthcare professionals to ensure records are up-to-date and accurate.
Implementing and maintaining efficient record-keeping systems.
Conducting regular audits to ensure data integrity.
What We're Looking For
We're seeking a candidate who brings professionalism, attention to detail, and a strong sense of responsibility to the role. To succeed in this position, you'll need:
At least 1 year of experience in medical records management or a related field.
A solid understanding of medical record-keeping standards and compliance regulations.
Excellent organizational and time-management skills.
Strong communication skills to work effectively with team members and healthcare professionals.
Proficiency with record-keeping software and systems is a plus.
Why Join Connected Crew?
While we do not currently offer additional benefits, you'll find that Connected Crew is a place where your skills are valued, and your contributions make a real difference. We are committed to creating a supportive and professional work environment where you can grow and succeed.
Our Culture and Values
At Connected Crew, we believe in teamwork, integrity, and excellence. We're a close-knit team that values collaboration and respects the important role each member plays in our success. If you're looking for a workplace where your efforts are appreciated and you can make a meaningful impact, you'll feel right at home here.
Ready to Apply?
If you're ready to take the next step in your career and join a team that values your expertise, we'd love to hear from you! Submit your application today and let's connect.
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$52k-84k yearly est. 12d ago
Medical Records Coordinator/Transportation
Avardis Health
Medical coder job in Archdale, NC
Looking for qualified Medical Records Coordinator to join our team!
Job Type: Full-Time
Are you an organized and detail-oriented professional with a passion for maintaining accurate and confidential medical records? We are seeking a Medical Records Coordinator/Transport to oversee and manage resident health information in compliance with federal and state regulations. If you thrive in a structured setting and want to make a meaningful impact in a skilled nursing facility, we want to hear from you! Join our dedicated team as a Medical Records Coordinator/Transport.
Major Responsibilities
Organize, plan, and direct the medical records department according to established policies.
Maintain active and discharged medical records using an established system.
Ensure compliance with recognized filing systems for efficient and secure record-keeping.
Accurately file nurses' notes, assessments, progress notes, lab reports, x-ray results, and other correspondence.
Collect, assemble, review, and file resident charts as required.
Assist the MDS Coordinator in scheduling resident assessments in line with facility and OBRA guidelines.
Review all records to ensure ICD-9-CM and ICD-10CM/DRG coding is accurate and complete.
Respond to medical record requests, ensuring compliance with federal and state laws.
Implement innovative systems and processes to improve record-keeping efficiency.
Minimum Qualifications
High school diploma or GED required.
Working knowledge of medical terminology, anatomy, and legal aspects of health information.
Certified Medical Records Practitioner preferred.
Experience with ICD-10CM/DRG coding and medical record maintenance.
Understanding of accreditation standards and compliance requirements.
Strong attention to detail, organization, and confidentiality.
As a Transportation Driver/CNA you will safely transport Residents to and from appointments, outings and activities while providing them with care, comfort and companionship they deserve. This is more than just a driving job- it's an opportunity to positively impact the lives of our residents while ensuring their safety and well-being.
Minimum Qualifications
High School diploma/Ged required
Valid Class C Driver's License with clean driving record
Experience as a patient transport van driver
Experience operating a company vehicle
Current Certified Nursing Assistant license
CPR certification or willingness to obtain within 6 months
Ability to lift, walk, and bend as needed to assist residents
Pay and Benefits
Competitive salary commensurate with experience
Comprehensive health, dental, and vision insurance
401(k)
Paid time off and holidays
Why Join Our Team
Get paid in advance with us: We offer access to your earned but unpaid wages.
Build your own schedule: Pick up shifts when and where you want to work. We have an easy-to-use scheduling app to find and book open shifts or request additional hours.
Shift options: Mornings, Afternoon, and Night's shift options available. Additional hours by request.
Innovative Purchasing Program: That allows you to buy thousands of products (technology, furniture, clothing, etc.) and pay over time. Zero interest, no credit check, no hidden fees.
Access to online learning 24/7: Our LMS offers free courses for senior care, health and human services industry. Use for free to help satisfy certifications or professional development. Available via computer or mobile, and many courses offer alternative languages.
Phone and auto discounts: Up to 20% on employee personal wireless accounts and auto rentals through designated vendors.
Employee Assistance Fund: In unexpected catastrophic situations you can confidentially apply for help.
Advocacy and Community Impact: We are committed to making a positive impact on the communities we serve. We partner with local organizations, host educational events, and advocate for policies that improve the health and lives of older adults everywhere.
About Us
We strive to be the leading provider of compassionate, comprehensive care that supports the physical, mental, and emotional well-being of patients, while also promoting respect and autonomy. Our goal is to create an environment where patients thrive, not just survive - where every aspect of their well-being is nurtured, from health and safety to social connections and quality of life.
We have innovative solutions for better health. As part of our commitment to excellence, we leverage the latest in healthcare technology to provide better outcomes for older adults. From telemedicine services and remote health monitoring to advanced diagnostic tools and customized wellness programs, we use innovation to make patient care accessible, efficient, and effective.
We also embrace new treatments, therapies, and approaches that can improve quality of life, whether it's through pain management, physical rehabilitation, or mental health support. By staying at the forefront of healthcare trends and continuously evolving our services, we ensure that patients receive the best possible care.
We are an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
Apply now! Our application process is quick and easy.
$27k-36k yearly est. 5d ago
Medical Records Coordinator
JBA International 4.1
Medical coder job in Charlotte, NC
A boutique personal injury law firm is seeking a Medical Records Coordinator in the North Lake area.
This is a direct hire full time in office position with an hourly rate of $15-$17. M-F
Position will consist of filing medical records both digitally and paper as well as keeping them updated. We're looking for strong typing and data entry skills. Tech savvy and fast paced. Medical records/ legal experience not required but a strong plus.
$15-17 hourly 60d+ ago
Certified Peer Specialist (PSS)
Higher Heights Home Care Inc.
Medical coder job in Wilson, NC
Job DescriptionBenefits/Perks
Competitive Compensation
Great Work Environment
Career Advancement Opportunities
We are seeking a Certified Peer Specialist (PSS) to join our team! As a Mental Health Aide, you will assist nurses and doctors with the day-to-day care of our patients, including assisting in eating, bathing, and even getting dressed. You may occasionally accompany patients for tests or treatments, assist with restocking equipment or supplies, and strive to create a safe, clean environment for our patients and other staff. The ideal candidate is compassionate, works well within a team environment, and has strong communication and interpersonal skills.
Responsibilities
Assist doctors, nurses, and others aides in day-to-day care, including helping patients with basic functions
Maintain a clean, safe, healing environment for all staff and patients
Restock equipment and supplies, as needed
Maintain excellent records of patient interactions, and report anything concerning immediately
Qualifications
Strong communication and interpersonal skills
Strong problem-solving abilities
The ability to work well within a team environment
Positive, compassionate attitude helpful
$47k-71k yearly est. 6d ago
Medical Record Clerk
Us Tech Solutions 4.4
Medical coder job in Durham, NC
USTECH is a global firm providing a wide-range of talent on-demand and total workforce solutions. Through the USTECH Talent Network of 100% company-owned and managed offices, we provide highly-skilled professionals whose education, skills and experience are vetted and matched to your unique hiring needs, work environment and company requirements.
Our 24x7 global service delivery drives time and cost out of any recruiting and staffing process (15-30% cost reduction in most cases) across all of our services and solutions, providing you with the talent you need on-demand when, where and how you need it.
Job Description
Job Title : Medical Record Clerk
JOB ID- : (14809)
Location : Durham, NC 27713
Duration : (at first 1+ month contract)
Qualifications:
Candidate will need to have experience indexing medical records and scanning.
This is a special short term project.
Must be able to stand long periods of time and able to lift up to 50 lbs.
Thanks ,Asma.
Additional Information
All your information will be kept confidential according to EEO guidelines.
$29k-36k yearly est. 60d+ ago
Medical Records and Referrals Coordinator
Piedmont Health Services 4.3
Medical coder job in Burlington, NC
Job Description
What is PACE?
At Piedmont Health Senior Care, we are dedicated to enhancing the lives of seniors in our community through our Program of All-inclusive Care for the Elderly (PACE). We help seniors maintain their independence and continue living at home for as long as possible. We achieve this by offering comprehensive, personalized healthcare and related services, all tailored to the unique needs and aspirations of each senior we serve.
Our approach is unlike any other healthcare plan! PACE emphasizes a participant-centered strategy, focusing on providing the right care and services that best support each participant's unique needs and goals. We integrate and coordinate all aspects of care, leveraging a team of dedicated doctors, nurses, therapists, dieticians, and other specialized professionals who work together as a care team to manage and address the complete health needs of each.
Job Title - Medical Records and Referral Coordinator
Department - PACE
Reports to - Site Director
Benefits -
Medical, Dental, Vision, Life Insurance (Short & Long Term Disability)
403(b) Plan
Paid Holidays
CME (Continuing Medical Education)
About Position: The Medical Records and Referral Coordinator is responsible for maintaining an accurate and complete medical record per PHSC policy and procedure and for coordination of authorized participant appointments per PHSC policy and procedure.
Work Location: 1214 Vaughn Road Burlington, NC 27217 & 163 Chatham Business Dr, Pittsboro, NC 27312
Schedule: Monday through Friday, 8:00am - 5:00pm
This position will work 3 days per week at PACE Burlington on Monday/Wednesday/Friday and at PACE Pittsboro on Tuesday/Thursday.
Duties/ Responsibilities -
Complete referral documents in the electronic medical record.
Schedule appointments for referrals, contact families and participants with referral times to include mailing an appointment reminder card as well as a courtesy reminder call prior to the scheduled appointment; coordinate referral times with the participant's family first - if family is unavailable, arrange via PHSC Transportation Manager.
Match consultation documents with referral orders and close referrals out via the appointment database.
Work closely with Medical Records Coordinator to ensure consultation documents are processed efficiently and relevant goals are being met.
Schedule and coordinate outside appointments for participants based on days of attendance/time/availability of transportation services to include the coordination with clinical staff when an aide/family escort is needed.
Work with the Medical Providers to reschedule appointments as needed per our PHSC appointment guideline as well as based on transportation services availability.
Document appointments within Centricity and appointment database.
Notify Nurse Care Manager of any scheduled procedures and give forms to be filled out; need to go over with participant prior to the scheduled appointment.
Make weekly schedule for authorized appointments and distribute.
Complete appointment paperwork (chart note/rationale for visit/etc.)
Consistently follows authorization and referral policies and procedures to include maximum number of appointments that can be approved and arranged per day.
Audit medical records for being up-to-date and complete.
Ensure referrals are completed according to determined goals, and referrals reports for open, held, and closed appointments are reviewed on at least a weekly basis with supervisor, providers, and Site Director.
Provides administrative support to the PACE Center as needed.
Ensures that Piedmont Health SeniorCare maintains an accurate and complete medical record as well as ensures the safety of participant confidential information, security of the facility and all data according to Federal and State Regulations.
Contacts outside offices for medical records, notes, images, follow-up and cancellations.
Ensures medical notes from specialty appointments, hospitalizations, etc are received and uploaded to the chart on a timely basis (no later than a week after appointment.
Close out the medical record of deceased and/or disenrolled participants.
Establishes and maintains medical records for each participant, including: requesting, scanning, uploading records, notes, images, follow-up and cancellations from external sources to include, labeling information once scanned into computer system as well as closes out referrals.
Achieves quality goals for medical records of a complete and accurate current medical record for every participant.
Abides by all established SeniorCare policies, rules and regulations, including patient, staff and SeniorCare information.
Perform all other duties as assigned.
Qualifications -
Education: Associates Degree in relevant field required or 2-3 years of relevant experience, education, or certification.
Required:
Must be able to work effectively in a team environment.
Strong oral and written communication skills.
Must meet a standardized set of competencies established by Piedmont Health SeniorCare and approved by CMS before working independently.
Preferred: One year of work experience with the frail or elderly preferred.
Immunizations: Be medically cleared for communicable diseases and have all immunizations up-to-date prior to beginning employment.
Pay Range : $17.66/Hourly - $23.74/Hourly
(
commensurate with years of experience)
EEO Statement
Piedmont Health Services, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to sex, sex stereotyping, pregnancy (including pregnancy, childbirth, and medical conditions related to pregnancy, childbirth, or breastfeeding), race, color, religion, ancestry or national origin, age, disability status, medical condition, marital status, sexual orientation, gender, gender identity, gender expression, transgender status, protected military or veteran status, citizenship status, genetic information, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
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$17.7-23.7 hourly 26d ago
Medical Records Clerk
Pinehurst Medical Clinic Inc. 4.3
Medical coder job in Pinehurst, NC
Pinehurst Medical Clinic (PMC)
PMC is a recognized healthcare provider in the communities of Moore County, Lee County, Cumberland County, Chatham County, and the surrounding six counties. Locally owned and managed, PMC offers a broad range of primary and specialty care services to the communities we serve. The physicians and healthcare team of professionals at PMC share a commitment to patient-centered care that is physician-led and utilizes the latest advances in medical technology. This combination of leading-edge medicine and deep compassion for the people we serve has been a hallmark of PMC since 1952. PMC consists of over 130 providers, approximately 750 employees, and 16 locations.
What will you do as a PMC Medical Records Clerk
As a PMC Medical Records Clerk, you will serve as an essential part of the patient's experience by assembling and maintaining electronic medical records and assuring the confidentiality of patient records in matters pertaining to the disclosure of patient treatment and medical diagnosis. You will also file and retrieve medical records while corresponding with doctors, nursing personnel, and other appropriate individuals in regard to EMR (Electronic Medical Records).
A day in the life of a PMC Medical Records Clerk may include:
Filing all patient records electronically, in a timely and accurate manner, making certain they are accessible for future use. Sorting and filing patient documents that are forwarded to the Medical Records Department either by paper or electronically
Maintain, organize, and manage patient records within the electronic medical record (EMR) system
Ensure accuracy, completeness, and timeliness of all documentation entered into the EMR
Scan, upload, index, and properly label incoming documents and external records
Maintain confidentiality and safeguard patient information at all times
Correct filing errors and resolve duplicate or incomplete records
Communicate professionally with staff, patients, and outside entities regarding record requests
Occasionally cross cover the switchboard or assist with release of information (ROI) in accordance with HIPAA regulations
Assists in answering telephones for medical record requests from physicians, nursing personnel, secretaries, and/or other appropriate personnel
Being a key piece in the PMC mission by providing the highest quality of care to our patients and the communities we serve
What we can offer
PMC is proud to support the total health and well-being of our team members so they can thrive personally and professionally. That's why, as part of the PMC team, you'll have a package of benefits that covers your health, well-being, family, and future. For more information regarding our benefits click here Benefits Information
Required Qualifications
High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
Preferred Qualifications
Prior medical records and Electronic Medical Records (EMR) experience preferred.
Shift: Day Shift (Monday through Friday) no weekends or holidays Pay Type: Hourly (Non-Exempt) The Pinehurst Medical Clinic is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations and provides equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.
$29k-35k yearly est. Auto-Apply 14d ago
EMR Support And Training Specialist
Tryon Medical Partners 4.0
Medical coder job in Charlotte, NC
General Job Summary: The EMR Support and Training Specialist is responsible for planning, developing, and delivering training programs related to the use of all Electronic Medical Record (EMR) systems and platforms across clinical and administrative teams. This role ensures that end-users are proficient and confident in using EMR tools to improve patient care, documentation accuracy, and overall workflow efficiency. The EMR Support and Training Specialist will also support onboarding, system upgrades, and ongoing optimization efforts.
(This is a full time position that will support our EMR and IT team in Charlotte, Monday to Friday 8 am to 5 pm).
Primary Job Responsibilities:
Assist in development and provide documentation and/or training covering AthenOne EMR optimizations, MIPS and other quality programs and version upgrades for staff and providers. Participate in testing for data security risks before deployment.
Develop, maintain, and deliver engaging EMR training programs and documentation for clinical and non-clinical staff, including physicians, nurses, and administrative personnel.
Conduct new hire EMR onboarding training and scheduled periodic courses, along with additional courses where needed.
Provide one-on-one and group training sessions, both virtually and in person.
Develop and maintain training materials such as manuals, tip sheets, videos, workflows, and e-learning modules tailored to user roles and needs.
Collaborate with IT and department leaders to identify training needs and develop role-specific content.
Stay informed of EMR updates, new functionality, and best practices; incorporate changes into training programs.
Support go-lives, upgrades, and major system changes by providing at-the-elbow and post-go-live support.
Assist in assessing user proficiency and documenting training compliance.
Collect feedback from users and adjust training approaches accordingly.
Collaborate with clinical and administrative teams to plan and execute the EMR rollout.
Conduct system testing (e.g., UAT - User Acceptance Testing) before go-live.
Identify bugs, escalate issues to vendors/IT teams, and validate resolutions to ensure system reliability.
Develop and deliver training materials and sessions for clinical, administrative, and support staff.
Provide ongoing training support to users, addressing technical questions and workflow issues related to EMR processes.
Triage and resolve inbound EMR training-related tickets submitted by end users across all supported platforms, including EMA, gMed, Artera, HealthiPass, MedChat, Dash, and others.
Submit case requests and escalations to vendor success communities as appropriate.
Proactively review release notes for all EMR platforms, assess workflow impacts well in advance of scheduled releases, and present recommendations to the IT/EMR Director and key stakeholders.
Participate in webinar-based training sessions relevant to current and future EMR workflows.
Conduct 30-, 60-, and 90-day post-onboarding check-ins with new employees to assess progress, address training needs, and identify opportunities for improvement.
Maintain awareness of available training curricula from supported EMR platforms and oversee a quarterly refresher training program.
Ability to travel between locations.
Other tasks as assigned.
Requirements
Education / Certification
Associate's or Bachelor's degree in healthcare, education, information systems, or related field preferred.
Minimum of 2 years of experience in a healthcare setting using an EMR system (Athenahealth
preferred
, Epic, Cerner, EMA, gGastro, etc.).
Athenahealth Certified Trainer preferred.
Epic Credentialed Trainer or Epic Proficient preferred.
Certified Professional in Healthcare Information and Management Systems (CPHIMS) preferred.
Experience
Prior experience in training, teaching, or instructional design preferred.
Clinical background (e.g., RN, MA, LPN) is a plus but not required.
Strong understanding of EMR systems and clinical workflows.
Excellent communication, presentation, and interpersonal skills.
Ability to explain complex systems in an easy-to-understand way for various learning styles.
Skilled in Microsoft Office Suite and digital learning platforms (e.g., Articulate, Captivate, LMS).
Organized, self-directed, and able to manage multiple projects simultaneously.
Strong problem-solving and troubleshooting skills.
Physical Requirements
Work consistently requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pulling.
Must be able to lift and support weight of 35 pounds
Ability to concentrate on details.
Use of computer for long periods of time.
$26k-33k yearly est. Auto-Apply 2d ago
Medical Records Coder II-Inpatient
Duke's Fuqua School of Business
Medical coder job in North Carolina
PRMO Established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke Primary Care. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke's reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.
Please note: This is NOT a remote work opportunity for candidates that reside in North Carolina, South Carolina, Georgia, Florida, Texas, or Virginia.
General Description of the Job Class
The Medical Records Coder II (Inpatient) is a certified Coder. Coordinate/review the work of subordinate employees and assist with the training and continuing education programs. Code medical records utilizing ICD-10-CM, ICD-10-PCS, and/or 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.
Duties and Responsibilities of this Level
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, ICD-10-PCS, and/or CPT coding conventions.
Coordinate/review the work of designated employees. Ensure quality and quantity of work performed through regular audits.
Assist with research, development, and presentation of continuing education programs on areas of specialization.
Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding conventions. Sequence the diagnoses and procedures using coding guidelines. Ensure DRG/APC assignment is accurate. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
Consult with and educate 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 to effectively apply ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
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.
Assist with special projects as required.
Perform other related duties incidental to the work described herein.
Required Qualifications at this Level
Education:
High school diploma required.
Experience:
RHIA certification-no experience required
RHIT certification-no experience required
CCS certification-Two years of coding experience required (Must be in the service the applicant is applying for)
CPC or HCS-D certification, years of coding experience required
Degrees, Licensures, 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) Homecare Coding
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 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.