Job Description

1. 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.

   1. Prepare daily& monthly coding audit reports.

   2. Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.

   3. Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered.

   4. Ensures coding is as per DOH guidelines and regulations.

   5. Provides feedback to Doctors regarding coding errors or oversights.

   6. Constantly updates to the latest coding versions and DOH coding directives.

   7. Maintain inter and interdepartmental communication for the smooth functioning of the department.

   8. Strictly adheres to organization’s regulations and policies especially those related to infection control, patient safety, ADOSH, DOH, JCI and ISO.

   9. Supports Continuous Quality Improvement and participates and contributes to all the quality assurance activities of the service.

   10. Participates and contributes in scheduled in-service training programs, In house activities, conferences or other programs as requested.

   11. Maintains confidentiality as per the agreement signed.

   12. Demonstrates the ability to listen to others in promoting effective communication.

   13. Develops thorough understanding of policies and procedures of the hospital and demonstrates respect for them.

   14. Carries out other duties when requested by the Head of department.

• Checks and sequences the most accurate ICD-9-CM, CPT, HCPCS, DRG, and other codes for diagnoses and procedures based on documented information
• Ensures final diagnoses and operative procedures stated by the physician are valid and complete
• Prepares daily and monthly coding audit reports
• Abstracts necessary information from health records to identify secondary complications and co-morbid conditions
• Evaluates records for documentation consistency and adequacy
• Ensures final diagnosis accurately reflects the care and treatment provided
• Ensures coding compliance with DOH guidelines and regulations
• Provides feedback to doctors regarding coding errors or oversights
• Keeps updated with the latest coding versions and DOH directives
• Maintains interdepartmental communication for smooth department functioning
• Adheres strictly to organizational policies, including infection control, patient safety, ADOSH, DOH, JCI, and ISO standards
• Supports continuous quality improvement and participates in quality assurance activities
• Participates in training programs, in-house activities, conferences, and other assigned programs
• Maintains confidentiality as per the signed agreement
• Demonstrates effective communication and active listening skills
• Develops a thorough understanding of hospital policies and procedures and adheres to them
• Performs additional duties as assigned by the Head of Department

Qualifications:

• Graduate in Allied Health Sciences or a related field
• Certified Coding Associate (CCA) from AHIMA

Experience:

• Minimum 2 years of coding experience

Skills:

• Computer literacy
• Excellent command of spoken and written English