IP Medical Coder

• 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.

  • Prepare daily& monthly coding audit reports.
  • Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
  • Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered.
  • Ensures coding is as per DOH guidelines and regulations.
  • Provides feedback to Doctors regarding coding errors or oversights.
  • Constantly updates to the latest coding versions and DOH coding directives.
  • Maintain inter and interdepartmental communication for the smooth functioning of the department.
  • Strictly adheres to organization’s regulations and policies especially those related to infection control, patient safety, OSHMS, DOH, JCI and ISO.
  • Supports Continuous Quality Improvement and participates and contributes to all the quality assurance activities of the service.
  • Participates and contributes in scheduled in-service training programs, In house activities, conferences or other programs as requested.
  • Maintains confidentiality as per the agreement signed.
  • Demonstrates the ability to listen to others in promoting effective communication.
  • Develops thorough understanding of policies and procedures of the hospital and demonstrates respect for them.
  • Carries out other duties when requested by the Head of department.

• Reviews and sequences accurate ICD-9-CM, CPT, HCPCS, DRG , and other applicable codes for diagnoses and procedures based on documented clinical information.

• Ensures final diagnoses and operative procedures documented by physicians are valid, complete, and compliant .

• Prepares daily and monthly coding audit reports .

• Abstracts required information from health records to identify secondary complications and co-morbid conditions .

• Evaluates medical records for documentation consistency, adequacy, and accuracy , ensuring diagnoses reflect the care and treatment provided.

• Ensures coding compliance with DOH guidelines and regulatory requirements .

• Provides constructive feedback to physicians regarding coding errors or documentation gaps.

• Stays updated with the latest coding standards, revisions, and DOH directives .

• Maintains effective intra- and inter-departmental communication to support smooth departmental operations.

• Adheres strictly to organizational policies, including infection control, patient safety, OSHMS, DOH, JCI, and ISO standards .

• Supports Continuous Quality Improvement (CQI) initiatives and actively participates in quality assurance activities.

• Participates in in-service training programs, in-house activities, conferences , and other assigned programs.

• Maintains patient and organizational confidentiality as per signed agreements.

• Demonstrates effective listening and communication skills to promote collaboration.

• Develops a thorough understanding of hospital policies and procedures and demonstrates compliance.

• Performs additional duties as assigned by the Head of Department.

• Graduate in Allied Health Sciences or a related field

• Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA)

Experience

• Minimum of two (2) years of professional coding experience

Skills

• Strong computer literacy
• Excellent oral and written communication skills in English