Job Description

GENERAL DESCRIPTION

To ensure accurate and timely coding of diagnoses and procedures using ICD 10 / ICD 11 standards international guidelines,submission of reportingand ensure the maintenance of patient confidentiality and delivery of excellent service in accordance with accepted professional standards set by the hospital and government legislation.

JOB

Main Responsibilities

• Assist in checking return of medical record folders from wards and movements are accurately documented and tracked.
• Ensure accuracy in assigning ICD and external cause code / procedure codes for all inpatient cases based on discharge diagnoses, in accordance with ICD regulations for statistical and reporting purposes.
• Ensure the accuracy and consistency of ICD coding by conducting regular cross-checking and coding audits in accordance with established standards and guidelines.
• Review, check, and validate medical records, discharge summaries, and related documentation to ensure accuracy, completeness, and consistency.
• Conduct administrative audits and produce reports on the completeness, legibility, and accuracy of medical record documentation.
• Prepare, organize, and submit monthly E-Reporting and SMRP data to the Ministry of Health (MOH), mortality statistics to Group Clinical, KPJHQ and hospital management within the timelines given.
• Provide and assist in the preparation and submission of coding-related reports, summaries, and analyses for state district center and hospital management use.
• Register and submit cancer cases to the National Cancer Registry in compliance with MOH guidelines and reporting standards (if applicable)
• Gather and distribute reports on notification of infectious diseases to the MOH via email / fax or through the e-Notification system within the stipulated time (if applicable)
• Gather, collect, and dispatch the external form from the nearest JPN branch within the stipulated time.
• Indent and collect the external form from the nearest JPN branch to ensure availability.
• Liaise and communicate with medical practitioners to clarify incomplete, uncertain, or unclear documentation in patient medical records.
• Liaise with Information Technology (IT) services for change request via the system to register new ICD code in the system.

Other Duties and Responsibilities

• Perform any other responsibilities assigned by immediate superior or hospital management.

JOB REQUIREMENT

Education:

• Diploma in healthcare management or bachelor's degree in health administration or other relevant qualifications.
• Certified Clinical Coder or equivalent credential preferred.

Knowledge and Experiences:

• Minimum 1–2 years of coding experience (fresh graduates may be considered).
• Knowledge of PDPA and International Classification Diseases (ICD 10 & ICD 11)
• Familiarity working in HIMS / medical records
• Experience of electronic medical records / hospital information system (HIS).

Skills & Competencies:

Special skills required

• Strong analytical and problem-solving skills.
• Detail-oriented with a focus on accuracy.
• Proficiency in Microsoft Excel and PowerPoint.

Personal attributes

• Results-oriented mindset, with the ability to work under pressure to meet deadlines.
• Self-motivated and able to work independently.
• Strong ethics and integrity.
• Openness to learning and adapting to change.
• A collaborative and team-oriented approach.