Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.
Responsibilities:
Assigns accurate ICD-9 / ICD-10-CM / CPT / HCPCS / DRG codes for diagnoses and procedures based on documented clinical information.
Ensures final diagnoses and operative procedures documented by physicians are valid and complete.
Abstracts relevant information from health records to identify secondary complications and co-morbidities.
Reviews medical records for documentation consistency and adequacy, ensuring diagnoses reflect the care provided.
Computes and assigns correct DRG coding for all inpatient cases.
Provides training and guidance to coders and Medical Records Technicians, including updates on coding standards and regulations.
Analyzes physician documentation to ensure correct Evaluation & Management (E&M) level assignment using appropriate CPT codes.
Ensures coding compliance with HAAD guidelines and regulatory requirements.
Provides constructive feedback to physicians on coding discrepancies or documentation gaps.
Keeps up to date with the latest coding systems, versions, and HAAD directives.
Performs additional job-related duties as assigned.
Undertakes any other responsibilities assigned by the Head of Department (HOD) within the job scope.
OSH & Compliance Responsibilities:
Complies with all Occupational Safety & Health (OSH) and infection control policies and procedures.
Works in accordance with established OSH procedures and responsibilities.
Maintains familiarity with emergency and evacuation procedures.
Reports hazards, incidents, and near misses, and assists in risk assessments and incident reporting.
Adheres to waste management policies and procedures.
Participates in OSH and infection control training, mock drills, and awareness programs.
Utilizes appropriate personal protective equipment (PPE) and safety systems.
Qualifications:
Bachelor’s Degree in Allied Health Sciences or a related field.
Minimum 2 years of coding experience.
Valid certification:
Proficient in computer applications, including MS Office.
Excellent oral and written communication skills in English.
Performance Criteria:
Achieves core objectives aligned with management and stakeholder expectations.
Demonstrates ability to work collaboratively and maintain professional interactions.
Effectively manages multiple tasks, adapts to changing priorities, and meets deadlines.