Medical Records Coder II-Inpatient

12/13/2025

The Medical Records Coder II (Inpatient) is responsible for reviewing complex medical records and accurately coding diagnoses and procedures. This role also involves coordinating the work of designated employees and ensuring quality through regular audits.

Working Hours

40 hours/week

Company Size

10,001+ employees

Language

English

Visa Sponsorship

About The Company

Duke University Hospital (DUH) is consistently rated as one of the best hospitals in the United States and is known around the world for its outstanding care and groundbreaking research. Driven to bring extraordinary discoveries to fruition, deliver cutting edge clinical services to patients, and apply care and compassion to all stages of care, we maintain an unwavering focus on making the individuals and communities we serve healthier. Today, DUH is the flagship of the Duke University Health System and a full-service, 957-bed, tertiary and quaternary academic medical center. Ranked nationally in 10 adult specialties by U.S. News and World Report for 2019-2020 and ranked first in North Carolina and first in the Raleigh-Durham area, care is delivered with inspiring passion and a deep commitment to put the person who needs our care at the center of everything we do.

About the Role

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. <h1>General Description of the Job Class</h1> 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. <h1>Duties and Responsibilities of this Level</h1> 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 <div class="WordSection1">Education: High school diploma required. Experience:<ul><li class="MsoBodyText">RHIA certification-no experience required</li><li class="MsoBodyText">RHIT certification-no experience required</li><li class="MsoBodyText">CCS certification-Two years of coding experience required (Must be in the service the applicant is applying for)</li><li class="MsoBodyText">CPC or HCS-D certification, years of coding experience required</li></ul></div> <h3>Degrees, Licensures, Certifications</h3> Must hold one of the following active/current certifications: <ul><li class="MsoBodyText">Registered Health Information Administrator (RHIA) Hospital Coding </li><li class="MsoBodyText">Registered Health Information Technician (RHIT) Hospital </li><li class="MsoBodyText">Coding Certified Coding Specialist (CCS) Hospital Coding</li><li class="MsoBodyText">Certified Professional Coder (CPC)</li><li class="MsoBodyText">Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding</li></ul> 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.

Key Skills

ICD-10-CMICD-10-PCSCPT-4 CodingMedical RecordsCoding GuidelinesAnatomyPhysiologyMedical TerminologyDisease ProcessesSurgical TechniquesAuditingEducation ProgramsConsultationDocumentationReimbursementQuality Assurance