Job description
• Check and assign the most accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for documented diagnoses and procedures.
• Ensure that the final diagnoses and operative procedures documented by the physician are valid and complete.
• Abstract all necessary information from health records to identify secondary complications and co-morbid conditions.
• Evaluate medical records for documentation consistency and adequacy, ensuring the final diagnosis accurately reflects the care and treatment provided.
• Compute and assign the correct DRG coding for all inpatient cases.
• Provide training and guidance to coders and Medical Records Technicians, updating them on new coding rules and regulations as required.
• Analyze physicians' documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.
• Ensure coding complies with HAAD guidelines and regulations.
• Provide feedback to physicians regarding coding errors, discrepancies, or documentation oversights.
• Stay up to date with the latest coding versions and HAAD coding directives.
• Perform miscellaneous job-related duties as assigned.
• Perform any other duties assigned by the HOD from time to time within the scope of the job title.
• Comply with all OSH and infection control policies, standards, and procedures, and cooperate with hospital management to meet these requirements.
• Work in accordance with documented OSH procedures, instructions, and assigned responsibilities.
• Be familiar with emergency and evacuation procedures.
• Notify OSH hazards, incidents, near misses, and issues, and assist in the preparation of risk assessments and incident reports.
• Comply with waste management procedures and policies.
• Attend applicable OSH and infection control training programs, mock drills, and awareness sessions.
• Use appropriate personal protective equipment (PPE) and safety systems.
• Bachelor's degree in Allied Health Sciences or a related field.
• Minimum of two (2) years of medical coding experience.
• Valid Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification from the American Academy of Professional Coders (AAPC) .
• Computer literacy with proficiency in Microsoft Office applications.
• Excellent command of spoken and written English.
Performance Criteria:
• Achieve core objectives in line with the expectations of management and stakeholders.
• Demonstrate the ability to work constructively and interact professionally with colleagues and stakeholders.
• Effectively coordinate multiple tasks, adapt to changing priorities, and meet established deadlines.
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