Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations
- Check and sequence the most accurate ICD-9/ICD-10-CM/CPT/HCPCS/DRG/other codes for diagnoses and procedures based on documented information; ensure final diagnoses and operative procedures stated by physicians are valid and complete
- Abstract necessary information from health records to identify secondary complications and co-morbid conditions
- Evaluate records for documentation consistency and adequacy; ensure final diagnosis accurately reflects the care and treatment rendered; compute and assign correct DRG coding for all inpatient cases
- Provide training and guidance to other coders/Medical Records Technicians; update them with new coding rules and regulations as needed
- Analyze doctors’ documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT code
- Ensure coding is compliant with HAAD guidelines and regulations
- Provide feedback to doctors regarding coding errors or oversights
- Stay updated with the latest coding versions and HAAD coding directives
- Perform miscellaneous job-related duties as assigned
- Perform other tasks or duties assigned by the HOD from time to time within the scope of the job title
- Occupational Safety & Health (OSH) and Infection Control Responsibilities
- Comply with all OSH and infection control policies, standards, and procedures; cooperate with hospital management to meet requirements
- Work in accordance with documented OSH procedures and instructions, including specific responsibilities
- Be familiar with emergency and evacuation procedures
- Report OSH hazards, incidents, near misses, and assist with risk assessments and incident reports
- Comply with waste management procedures and policies
- Attend applicable OSH/Infection Control training programs, mock drills, and awareness programs
- Use appropriate personal protective equipment (PPE) and safety systems
- Graduate with a Bachelor’s Degree in Allied Health Sciences or related field
- Minimum of two (2) years of coding experience
- Valid certification:
- Certified Coding Associate (CCA) – AHIMA, or
- Certified Professional Coder (CPC) – AAPC
- Computer literacy, including proficiency in MS Office
- Excellent command of oral and written English
- Performance Criteria
- Achievement of core objectives in line with the expectations of management and stakeholders
- Ability to work constructively and interact professionally with others
- Ability to coordinate multiple tasks, adjust to changing priorities, and meet deadlines
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