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Hospital Inpatient Coding - Medical Records Coder II

Applicants must be located in, or willing to relocate to, North Carolina

The Medical Records Coder II is a certified Coder which coordinates/reviews the work of subordinate employees and assist with the training and continuing education programs. Code medical records utilizing ICD-10-CM/PCS 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.


  • 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-4 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 and 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 and 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.

Education and Experience:

  • Must hold one or more of the following active/current certifications:
    • Registered Health Information Administrator (RHIA) Hospital Coding, 2 years experience preferred
    • Registered Health Information Technician (RHIT) Hospital Coding, 2 years experience preferred
    • Certified Coding Specialist (CCS) Hospital Coding with one year of coding experience required.
    • AHIMA preferred.
  • 1-2 years of technical coding experience
  • High school diploma required.

Preferred Skills and Abilities include:

  • Advanced ICD-10-CM & CPT-4 coding conventions
  • Preferred Skills include ICD-10 training and experience
  • Anatomy and Physiology Medical Terminology
  • Extensive DRG/APC
  • Reimbursement knowledge
  • Coding software familiarity
  • Effective written and verbal communication skills
  • Data entry/CRT
  • ICD-10 training or experience
  • EPIC experience
  • ICD-10-CM experience
  • CPT-4 experience



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