Job Description

Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.

Responsibilities

• Checks and sequences the most accurate ICD-9/ICD-10-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures. Ensures final diagnoses and operative procedures stated by the physician are valid and complete.
• Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
• Evaluates records for documentation consistency and adequacy. Ensures the final diagnosis accurately reflects the care and treatment rendered and computes correct DRG coding for all inpatient cases.
• Provides training and guidance to other coders / Medical Records Technicians, updating them with new coding rules and regulations as necessary.
• Analyzes doctors’ documentation to ensure appropriate Evaluation & Management (E&M) levels are assigned using the correct CPT code.
• Ensures coding complies with HAAD guidelines and regulations.
• Provides feedback to doctors regarding coding errors or oversights.
• Keeps updated with the latest coding versions and HAAD coding directives.
• Performs miscellaneous job-related duties as assigned.
• Performs any other jobs or duties assigned by the HOD within the scope of the job title.
• Complies with all OSH and infection control policies, standards, and procedures, cooperating with hospital management to meet requirements.
• Works in accordance with documented OSH procedures and instructions, fulfilling specific responsibilities.
• Familiar with emergency and evacuation procedures.
• Notifies OSH hazards, incidents, near misses, and issues; assists with preparation of risk assessments and incident reports.
• Complies with waste management procedures and policies.
• Attends applicable OSH/Infection control training programs, mock drills, and awareness programs.
• Uses appropriate personal protective equipment and safety systems.

Qualifications

• Education & Certification:
  • Bachelor’s Degree in Allied Health Sciences or related fields.
  • Minimum 2 years of coding experience.
  • Valid Certified Coding Associate (CCA) certification from AHIMA or Certified Professional Coder (CPC) certification from AAPC.
• Technical Skills:
  • Computer literacy, including MS Office.
• Language Skills:
  • Excellent command of oral and written English.
• Performance Criteria:
  • Achievement of core objectives in line with management and stakeholder expectations.
  • Ability to work constructively and interact professionally with others.
  • Ability to coordinate multiple tasks, adapt to changing priorities, and meet deadlines.