Description

Job Description

Job Description

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

Responsibilities

• Reviews and assigns the most accurate ICD-9 / ICD-10-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.
• Abstracts all required information from medical records to identify secondary diagnoses, complications, and co-morbid conditions.
• Evaluates medical records for documentation accuracy, consistency, and completeness, ensuring diagnoses reflect the care and treatment provided.
• Computes and assigns accurate DRG coding for all inpatient cases.
• Provides training, guidance, and support to coders and Medical Records Technicians, including updates on new coding rules and regulations.
• Reviews physician documentation to ensure correct Evaluation and Management (E&M) levels are assigned using appropriate CPT codes.
• Ensures all coding practices comply with HAAD guidelines and regulatory requirements.
• Provides constructive feedback to physicians regarding coding errors, omissions, or documentation gaps.
• Maintains up-to-date knowledge of latest coding standards, versions, and HAAD directives.
• Performs miscellaneous job-related duties as assigned.
• Carries out additional tasks assigned by the Head of Department (HOD) within the scope of the job role.
• Complies with all Occupational Safety and Health (OSH) and Infection Control policies, standards, and procedures.
• Works in accordance with documented OSH procedures, instructions, and assigned responsibilities.
• Demonstrates familiarity with emergency and evacuation procedures.
• Reports OSH hazards, incidents, near misses, and assists in risk assessments and incident report preparation.
• Complies with waste management policies and procedures.
• Participates in applicable OSH and Infection Control training programs, mock drills, and awareness sessions.
• Ensures proper use of personal protective equipment (PPE) and safety systems at all times.

Qualifications

• Bachelor’s degree in Allied Health Sciences or a related field.
• Minimum of two (2) years of medical coding experience.
• Valid certification as either:
  • Certified Coding Associate (CCA) – AHIMA, or
  • Certified Professional Coder (CPC) – AAPC.
• Strong computer literacy, including proficiency in MS Office applications.
• Excellent oral and written English communication skills.

Performance Criteria:

• Achievement of core objectives in alignment with management and stakeholder expectations.
• Ability to work constructively and maintain professional interpersonal relationships.
• Strong multitasking, coordination, and time-management skills, with the ability to adapt to changing priorities and meet deadlines.