Responsibilities
Checks and sequences accurate ICD-9-CM, CPT, HCPCS, DRG, and other relevant codes for diagnoses and procedures.
Ensures final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
Prepares daily and monthly coding audit reports.
Abstracts necessary information from medical records to identify secondary complications and co-morbid conditions.
Evaluates records for documentation consistency, adequacy, and accuracy, ensuring diagnoses reflect the care and treatment provided.
Ensures coding is compliant with DOH guidelines and regulations.
Provides feedback to physicians regarding coding errors or documentation oversights.
Keeps updated with latest coding versions and DOH coding directives.
Maintains effective intra- and inter-departmental communication for smooth department functioning.
Adheres strictly to organizational policies, especially regarding infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.
Supports Continuous Quality Improvement (CQI) initiatives and contributes to all quality assurance activities.
Participates in in-service training programs, in-house activities, conferences, and other assigned programs.
Maintains confidentiality in accordance with signed agreements.
Demonstrates effective listening and communication skills to promote collaboration.
Develops thorough understanding of hospital policies and procedures and shows respect for them
Performs additional duties as assigned by the Head of Department.
Qualifications
A Graduate in Allied Health Sciences or related areas
Certified Coding Associate (CCA) certification from American Health Information Management Association (AHIMA)
Experience
At least Eight (2) years of coding experience
Skills
Computer Literacy
Excellent command of oral and written English