Medical Records Coder II – Ophthalmology

Duke Careers

Certified Coder coordinating and reviewing medical records using ICD-10-CM and CPT-4 coding conventions for Duke Health. Ensuring appropriateness of reimbursement and providing education on coding practices.

Posted 7/23/2026full-timeRemote • Alabama, Arizona, Connecticut, District of Columbia, Florida, Illinois, Iowa, Kentucky, Louisiana, Maine, Missouri, Montana, New Hampshire, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington • 🇺🇸 United StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in ICD-10-CM and CPT-4 coding conventions, ensuring accurate coding and optimal reimbursement through thorough understanding of medical terminology, anatomy, and physiology. Proficient in conducting audits and training while effectively communicating with healthcare professionals to enhance coding practices.

Highest-signal resume keywords

ICD-10-CM CodingCPT-4 CodingDRG/APC Reimbursement KnowledgeRHIA CertificationRHIT Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical CodingData AbstractionCoding Guidelines ApplicationMedical Record ReviewDiagnosis Sequencing

Soft Skills

Effective CommunicationTraining and Education

Tools & Technologies

Coding Software

Certifications & Qualifications

RHIA CertificationRHIT CertificationCCS CertificationCPC CertificationHCS-D Certification

Industry Keywords

Medical TerminologyAnatomy and PhysiologyJoint Commission on Accreditation of Health OrganizationsHealth Care/Finance AdministrationMedical Review of North Carolina

About the role

Key responsibilities & impact

Coordinate/review the work of subordinate employees and assist with the training and continuing education programs.
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.
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 coding conventions.
Ensure quality and quantity of work performed through regular audits.
Assist with research, development, and presentation of continuing education programs in areas of specialization.
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.

Requirements

What you’ll need

High school diploma required.
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
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 N/A

Benefits

Comp & perks

Now offering a $10,000 sign-on bonus that will pay out in 4 equal installments over 24 months—6-month increments.