IP Medical Coder

1. DUTIES AND RESPONSIBILITIES

1. The incumbent checks and sequences the most accurate ICD-9/ ICD10-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. Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.

   2. Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Computes and gives the correct DRG coding all inpatients cases.

   3. Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

   4. Analyzes doctors’ documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.

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

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

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

   1. Performs miscellaneous job-related duties as assigned.

   2. Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

OSH ROLES & RESPONSIBILITIES:

1. Comply with reasonable OSH instructions, policies and safe working procedures

   1. Use of appropriate personal protective equipment and safety systems.

   2. Be familiar with emergency and evacuation procedures

   3. Not willfully or recklessly endanger anyone’s health and safety

   4. Assist with the preparation of risk assessments

   5. Report OSH Hazards, incidents, Near misses and issues

   6. Reduce, Reuse, Recycling of waste as much as possible

   7. Attend all OSH Trainings, awareness programs and mock drills.

   8. Participates in the OSHMS audits, inspections, ensuring standards are maintained

Additional duties/responsibilities (related to ADHICS) assigned to this position in clear, concise language:

Health Information Literacy and Skills:

1. Adhere to information systems policies and procedures as required by Health Care Organization.

   Privacy, Confidentiality of Health Information:

   1. Follow security and privacy policies and procedures to the use of networks, including intranet and Internet.

   2. Follow confidentiality and security measures to protect electronic health information.

   3. Maintain data integrity and validity within an information system.

   4. Report any possible breaches of confidentiality in accordance with organizational policies.

   Health Information/Data Technical Security:

1. Apply departmental and organizational data and information system security policie

   Basic Computer Literacy Skills:

   1. Use basic word processing, spreadsheet and desktop presentation applications as applicable to your work.

   2. Demonstrate proficiency in Windows operating environment.

   3. Demonstrate use of email, addressing, forwarding, attachments, netiquette.

BCP ROLES & RESPONSIBILITIES:

3.29 Responsibilities of staff (including all contractors) are:

3.29.1 Achieving an adequate level of general awareness regarding business continuity Being aware of the contents of their service areas disaster recovery plan and any specific role or responsibilities allocated.

1. Participating actively in the business continuity programme when required

Ensuring information governance standards continue to be applied to data and information during an incident

Responsibilities

• The incumbent checks and sequences the most accurate ICD-9/ ICD10-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.

• 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. Computes and gives the correct DRG coding all inpatient cases.

• Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

• Analyzes doctors’ documentation to assure the appropriate Evaluation & Management (E&M) levels are assigned using the correct CPT code.

• 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.

• Performs miscellaneous job-related duties as assigned.

• Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

OSH ROLES & RESPONSIBILITIES

• Comply with reasonable OSH instructions, policies and safe working procedures.

• Use of appropriate personal protective equipment and safety systems.

• Be familiar with emergency and evacuation procedures.

• Not willfully or recklessly endanger anyone’s health and safety.

• Assist with the preparation of risk assessments.

• Report OSH Hazards, incidents, near misses and issues.

• Reduce, reuse, and recycle waste as much as possible.

• Attend all OSH trainings, awareness programs, and mock drills.

• Participate in OSHMS audits and inspections, ensuring standards are maintained.

ADDITIONAL RESPONSIBILITIES (ADHICS)

Health Information Literacy and Skills

• Adhere to information systems policies and procedures as required by the healthcare organization.

Privacy, Confidentiality of Health Information

• Follow security and privacy policies and procedures for the use of networks, including intranet and internet.

• Follow confidentiality and security measures to protect electronic health information.

• Maintain data integrity and validity within an information system.

• Report any possible breaches of confidentiality in accordance with organizational policies.

Health Information/Data Technical Security

• Apply departmental and organizational data and information system security policies.

Basic Computer Literacy Skills

• Use basic word processing, spreadsheet, and desktop presentation applications as applicable to work.

• Demonstrate proficiency in Windows operating environment.

• Demonstrate use of email, including addressing, forwarding, attachments, and netiquette.

BCP ROLES & RESPONSIBILITIES

• Achieve an adequate level of general awareness regarding business continuity.

• Be aware of the contents of service area disaster recovery plans and any specific roles or responsibilities allocated.

• Participate actively in the business continuity program when required.

• Ensure information governance standards continue to be applied to data and information during an incident.

Qualifications

• A graduate of Bachelor’s Degree in Allied Health Sciences or related areas with at least two (2) years of coding experience with valid Certified Coding Associate (CCA) certification from American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification from American Academy of Professional Coders (AAPC).

• Computer Literacy, MS Office.

• Excellent command of oral and written English.

Performance Criteria

• Achievement of Core objectives in line with the expectations of the Management and stakeholders.

• Ability to work constructively and interact professionally with others.

• Ability to coordinate multiple tasks, adjust to changing priorities, and work within deadlines.

• Ability to attend meetings outside of normal business hours.