About this role
• The incumbent checks and sequences the most accurate ICD-9-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.
• Prepare daily& monthly coding audit reports.
• Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
• Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered.
• Ensures coding is as per DOH guidelines and regulations.
• Provides feedback to Doctors regarding coding errors or oversights.
• Constantly updates to the latest coding versions and DOH coding directives.
• Maintain inter and interdepartmental communication for the smooth functioning of the department.
• Strictly adheres to organization’s regulations and policies especially those related to infection control, patient safety, ADOSH, DOH, JCI and ISO.
• Supports Continuous Quality Improvement and participates and contributes to all the quality assurance activities of the service.
• Participates and contributes in scheduled in-service training programs, In house activities, conferences or other programs as requested.
• Maintains confidentiality as per the agreement signed.
• Demonstrates the ability to listen to others in promoting effective communication.
• Develops thorough understanding of policies and procedures of the hospital and demonstrates respect for them.
• Carries out other duties when requested by the Head of department.
• Reviews and sequences accurate ICD-9-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information.
• Ensures that final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
• Prepares daily and monthly coding audit reports.
• Abstracts all required information from medical records to identify secondary complications and co-morbid conditions.
• Evaluates medical records for documentation consistency, completeness, and adequacy, ensuring diagnoses accurately reflect the care and treatment provided.
• Ensures coding compliance with DOH guidelines, standards, and regulatory requirements.
• Provides timely and constructive feedback to physicians regarding coding errors, omissions, or documentation gaps.
• Remains updated with current coding systems, revisions, and DOH coding directives.
• Maintains effective intra- and inter-departmental communication to ensure smooth departmental operations.
• Strictly adheres to organizational policies and procedures, particularly those related to infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.
• Supports Continuous Quality Improvement (CQI) initiatives and actively participates in all quality assurance activities.
• Participates in scheduled in-service training programs, in-house activities, conferences, and other assigned educational programs.
• Maintains confidentiality in accordance with signed agreements and organizational policies.
• Demonstrates effective listening and communication skills to promote collaboration and teamwork.
• Develops a thorough understanding of hospital policies and procedures and demonstrates compliance at all times.
• Performs additional duties as assigned by the Head of Department.
• Graduate in Allied Health Sciences or a related field
• Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA)
Experience
• Minimum of two (2) years of coding experience
Skills
• Strong computer literacy
• Excellent oral and written English communication skills