Job Description

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, OSHMS, 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 final diagnoses and operative procedures documented by physicians are

valid, complete, and compliant

. Prepares

daily and monthly coding audit reports

. Abstracts required information from health records to identify

secondary complications and co-morbid conditions

. Evaluates medical records for

documentation consistency, adequacy, and accuracy

, ensuring diagnoses reflect the care and treatment provided. Ensures coding compliance with

DOH guidelines and regulatory requirements

. Provides

constructive feedback to physicians

regarding coding errors or documentation gaps. Stays updated with the

latest coding standards, revisions, and DOH directives

. Maintains effective

intra- and inter-departmental communication

to support smooth departmental operations. Adheres strictly to organizational policies, including

infection control, patient safety, OSHMS, DOH, JCI, and ISO standards

. Supports

Continuous Quality Improvement (CQI)

initiatives and actively participates in quality assurance activities. Participates in

in-service training programs, in-house activities, conferences

, and other assigned programs. Maintains

patient and organizational confidentiality

as per signed agreements. Demonstrates effective

listening and communication skills

to promote collaboration. Develops a thorough understanding of hospital

policies and procedures

and demonstrates compliance. 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 professional coding experience

Skills

Strong

computer literacy

* Excellent

oral and written communication skills in English