Coder II Facility HB, Coding Education

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Wake Forest Baptist Health
September 16, 2021
Winston-Salem, North Carolina
Job Type


Coder II Facility HB, Coding Education  "Job Details"

Winston-Salem, NC, United States

Job Identification


Job Category



  • Medical Center Blvd, Winston Salem, NC, 27157, US

Posting Date

09/15/2021, 09:37 PM

Job Schedule

Full time

Job Shift


Job Description

Coder II Facility HB, Coding Education

40 hours per week, day shift

JOB SUMMARY:  Responsible for the coding of medical information into the WakeOne medical records abstracting system and for monitoring completion of the coding function through established best practice processes, professional and regulatory coding guidelines. Assigns ICD CM/PCS codes (Inpatient) and ICD CM/CPT codes (Outpatient) as directed for respective encounters.  Reviews and edits associated facility charges as directed for the encounters assigned.  Data reported is used for statistical, financial and billing purposes and to meet licensure requirements.

EDUCATION/EXPERIENCE: Graduation from an accredited medical coding program and two years' experience as a Coder I in an acute care facility or a similar position in another facility with demonstrated competency of knowledge base.  Satisfactory completion of college level courses in anatomy, physiology and medical terminology preferred.  EPIC health information system experience preferred.

LICENSURE, CERTIFICATION, and/or REGISTRATION: Coding certification CCA, CIC, CPC-H, CPC, CCS, RHIT, or RHIA required.

1.    Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards.
2.    Applies correct ICD CM/PCS (Inpatient) and ICD CM/CPT codes (Outpatient) guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity.
3.    Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded.
4.    Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
5.    Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation.
6.    Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy.  Brings identified concerns to Manager Coding for resolution.
7.    Assigns the MS DRG and MCC/CCs that most appropriately reflects documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department (Inpatient).
8.    Reviews department-specified reports daily to identify charts that need to be coded based and prioritizes as per department-specific guidelines and within designated timelines.
9.    Follows up to ensure that any edits that prevent an account from dropping are corrected within established timelines.
10.    Produces specific reports on a monthly basis per established parameters.
11.    Responds to inquiries from Patient Accounts or other departments as requested.  Communicates with Manager when trending request volumes impact productivity.
12.    Participates in on site and/or external training workshops as opportunities arise; maintains credentials, if applicable, and submits written evidence of maintenance.
13.    Participates as a member of the Clinical Documentation Management Program.
14.    Performs administrative duties in support of the overall coding function as assigned and assists Managers as requested.


  • Ability to concentrate for extended periods.
  • Knowledge of medical terminology and basic anatomy, physiology, pathophysiology, and pharmacology with ability to apply  knowledge to the coding process.
  • Demonstrates skill in coding classification systems, diagnosis, procedure selection, and sequencing guidelines.
  • Knowledge of APC prospective payment system.
  • Demonstrates competence in coding and correct extrapolation of official coding and select billing guidelines to specific coding situations.
  • Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate code assignment.
  • Demonstrates full understanding and is compliant with correct coding initiative guidelines, regulatory requirements regarding coding of medical information including but not limited to external regulatory agencies such as Quality Improvement Organizations (QIOs), the Centers for Medicare & Medicaid Services (CMS), other payers, and the Joint Commission.
  • Ability to apply broad guidelines to specific coding situations; independently utilizing discretion and a significant level of analytic ability.
  • Effective verbal and written communication and customer service skills.
  • Ability to operate multiple Windows based software applications.
  • Ability to solve problems, close attention to detail, make decisions independently, and manage multiple demands.
  • Demonstrates continuous learning as evidenced by personally developed reference materials, online publications etc., to stay abreast of new and revised guidelines, practices and terminology, for reference and application.


  • Clean, comfortable, well-lit area
  • Moderate noise environment


Amount of time spent performing the following activities:
0%    35%    65%
to    to    to
35%    65%    100%    N/A    Activity
X                Standing
X                Walking
X        Sitting
X                Bending
X                Reaching with arms
X        Finger and hand dexterity
X            Talking
X            Hearing
X        Seeing
X                Lifting, carrying, pushing and or pulling:
X                20 lbs. maximum
X    50 lbs. maximum
X    100 lbs. maximum

About Us

Wake Forest Baptist Health and Atrium Health have joined forces in a strategic combination that will enhance care, transform medical education and create economic opportunity for countless lives in North Carolina and beyond. As a part of that combination, the two health systems will be integrating technology and platforms, including our career sites.

This means that although you are applying on the Wake Forest Baptist Health Career Site, you receive communications from the Atrium Health Recruitment Team. Please know that this is an expected process, and thanks in advance for your flexibility.

Wake Forest Baptist Health ( is a nationally recognized academic health system in Winston-Salem, North Carolina, with an integrated enterprise including educational and research facilities, hospitals, clinics, diagnostic centers, and other primary and specialty care facilities serving 24 counties in northwest North Carolina and southwest Virginia.

It comprises: a regional clinical system with more than 300 locations, 2,100 physicians and 1,535 acute care beds; Wake Forest School of Medicine; and Wake Forest Innovations, which promotes the commercialization of research discoveries and operates Innovation Quarter, an urban research and business park specializing in biotechnology, materials science and information technology.  Wake Forest Baptist’s clinical, research and educational programs are consistently ranked among the best in the country.

About the Team


Wake Forest Baptist Health's mission is to improve the health of our region, state and nation by:

  • Generating and translating knowledge to prevent, diagnose and treat disease.
  • Training leaders in health care and biomedical science.
  • Serving as the premier health system in our region, with specific centers of excellence recognized as national and international care destination.


Wake Forest Baptist Health is a preeminent learning health system that promotes better health for all through collaboration, excellence and innovation.



  • Demonstrate the highest standards of patient-centered care, education, research and operational effectiveness


  • Responsive to the physical, emotional, spiritual and intellectual needs of all


  • Cultivate selfless contribution for the greater good


  • Demonstrate fairness, honesty, sincerity and accountability


  • Demonstrate respect for and inclusion of all backgrounds, identities, experiences, and perspectives


  • Foster mutual respect, facilitate professional growth and mentorship, and reward teamwork and collaboration


  • Promote creativity to enhance discovery and the application of knowledge


  • Embrace a culture of reliability through better process design and accountability

Patient and Family Promise

We promise to:

  • Keep you safe.
  • Care for you.
  • Involve you and your family.
  • Respect you and your time.

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