OP Medical Coder

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.

Responsibilities

• Checks and sequences accurate ICD-9-CM, CPT, HCPCS, DRG, and other relevant codes for diagnoses and procedures.
• Ensures final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
• Prepares daily and monthly coding audit reports.
• Abstracts necessary information from medical records to identify secondary complications and co-morbid conditions.
• Evaluates records for documentation consistency, adequacy, and accuracy, ensuring diagnoses reflect the care and treatment provided.
• Ensures coding is compliant with DOH guidelines and regulations.
• Provides feedback to physicians regarding coding errors or documentation oversights.
• Keeps updated with latest coding versions and DOH coding directives.
• Maintains effective intra- and inter-departmental communication for smooth department functioning.
• Adheres strictly to organizational policies, especially regarding infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.
• Supports Continuous Quality Improvement (CQI) initiatives and contributes to all quality assurance activities.
• Participates in in-service training programs, in-house activities, conferences, and other assigned programs.
• Maintains confidentiality in accordance with signed agreements.
• Demonstrates effective listening and communication skills to promote collaboration.
• Develops thorough understanding of hospital policies and procedures and shows respect for them.
• Performs additional duties as assigned by the Head of Department.

Qualifications

• A Graduate in Allied Health Sciences or related areas
• Certified Coding Associate (CCA) certification from American Health Information Management Association (AHIMA)

Experience

• At least Eight (2) years of coding experience

Skills

• Computer Literacy
• Excellent command of oral and written English