Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.
Responsibilities
- Review and sequence accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for documented diagnoses and procedures.
- Ensure final diagnoses and operative procedures documented by physicians are valid, accurate, and complete.
- Abstract relevant information from medical records to identify secondary complications, co-morbid conditions, and other reportable conditions.
- Evaluate medical records for documentation consistency, completeness, and adequacy.
- Ensure final diagnoses accurately reflect the care and treatment provided.
- Assign and validate the appropriate DRG codes for all inpatient cases.
- Provide training and guidance to Medical Coders and Medical Records Technicians on coding practices.
- Keep coding staff updated on new coding rules, regulations, and guidelines.
- Review physicians’ documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.
- Ensure all coding activities comply with applicable HAAD guidelines and regulations.
- Provide feedback to physicians regarding coding errors, documentation gaps, and oversights.
- Stay updated with the latest coding versions, standards, and HAAD coding directives.
- Perform miscellaneous job-related duties as assigned.
- Perform any other duties assigned by the HOD within the scope of the job role.
- Comply with all OSH and infection control policies, standards, and procedures.
- Follow documented OSH procedures, instructions, and assigned responsibilities.
- Maintain familiarity with emergency and evacuation procedures.
- Promptly report OSH hazards, incidents, near misses, and other safety-related issues.
- Assist with the preparation of risk assessments and incident reports.
- Comply with waste management policies and procedures.
- Attend applicable OSH and infection control training programs, mock drills, and awareness programs.
- Ensure appropriate use of personal protective equipment (PPE) and safety systems.
Qualifications
- Bachelor’s Degree in Allied Health Sciences or a related field from a recognized institution.
- Minimum 2 years of Medical Coding experience.
- Valid Certified Coding Associate (CCA) certification from AHIMA or Certified Professional Coder (CPC) certification from AAPC.
- Good computer literacy with proficiency in Microsoft Office applications.
- Excellent command of spoken and written English.
- Achieve core objectives in line with the expectations of management and relevant stakeholders.
- Demonstrate the ability to work constructively and interact professionally with colleagues and stakeholders.
- Ability to coordinate multiple tasks, adapt to changing priorities, and consistently meet deadlines.
