IP Medical Coder

Role Overview

IP Medical Coder at NMC Healthcare. This role ensures proper coding of documents in accordance with regulatory coding guidelines and regulations.

Role Purpose

To assign accurate clinical codes and ensure documentation compliance with regulatory requirements, maintaining the integrity of medical records through systematic review and quality assurance.

Key Responsibilities

Clinical Coding & Documentation

• Assign accurate ICD-9, ICD-10-CM, CPT, HCPCS, and DRG codes for diagnoses and procedures based on documented clinical information.
• Ensure final diagnoses and operative procedures documented by physicians are valid and complete.
• Abstract relevant information from health records to identify secondary complications and co-morbidities.
• Review medical records for documentation consistency and adequacy, ensuring diagnoses reflect the care provided.
• Compute and assign correct DRG coding for all inpatient cases.
• Analyze physician documentation to ensure correct Evaluation & Management (E&M) level assignment using appropriate CPT codes.
• Provide constructive feedback to physicians on coding discrepancies or documentation gaps.

Compliance & Regulatory

• Ensure coding compliance with HAAD guidelines and regulatory requirements.
• Keep up to date with the latest coding systems, versions, and HAAD directives.

Training & Collaboration

• Provide training and guidance to coders and Medical Records Technicians, including updates on coding standards and regulations.
• Demonstrate ability to work collaboratively and maintain professional interactions.
• Effectively manage multiple tasks, adapt to changing priorities, and meet deadlines.

General Duties

• Achieve core objectives aligned with management and stakeholder expectations.
• Perform additional job-related duties as assigned.
• Undertake any other responsibilities assigned by the Head of Department (HOD) within the job scope.

Occupational Safety & Health and Compliance

• Comply with all Occupational Safety & Health (OSH) and infection control policies and procedures.
• Work in accordance with established OSH procedures and responsibilities.
• Maintain familiarity with emergency and evacuation procedures.
• Report hazards, incidents, and near misses, and assist in risk assessments and incident reporting.
• Adhere to waste management policies and procedures.
• Participate in OSH and infection control training, mock drills, and awareness programs.
• Utilize appropriate personal protective equipment (PPE) and safety systems.

Qualifications & Experience

• Bachelor's Degree in Allied Health Sciences or a related field.
• Minimum 2 years of coding experience.
• Valid certification: Certified Coding Associate (CCA) – AHIMA, or Certified Professional Coder (CPC) – AAPC.

Skills & Competencies

• Proficient in computer applications, including MS Office.
• Excellent oral and written communication skills in English.