IP Medical Coder

Role Overview

IP Medical Coder at NMC Healthcare, responsible for ensuring accurate and compliant medical coding across inpatient records using standardized coding systems and regulatory guidelines.

Role Purpose

Review, abstract, and assign the most accurate ICD-9-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information, while ensuring compliance with DOH guidelines, regulatory requirements, and organizational quality standards.

Key Responsibilities

Coding & Documentation Review

• Review and sequence accurate ICD-9-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information.
• Ensure final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
• Evaluate medical records for documentation consistency, adequacy, and accuracy, ensuring diagnoses reflect the care and treatment provided.
• Abstract required information from health records to identify secondary complications and co-morbid conditions.

Compliance & Regulatory Adherence

• Ensure coding compliance with DOH guidelines and regulatory requirements.
• Adhere strictly to organizational policies, including infection control, patient safety, OSHMS, DOH, JCI, and ISO standards.
• Stay updated with the latest coding standards, revisions, and DOH directives.

Quality Assurance & Reporting

• Prepare daily and monthly coding audit reports.
• Support Continuous Quality Improvement (CQI) initiatives and actively participate in quality assurance activities.

Communication & Collaboration

• Provide constructive feedback to physicians regarding coding errors or documentation gaps.
• Maintain effective intra- and inter-departmental communication to support smooth departmental operations.
• Demonstrate effective listening and communication skills to promote collaboration.

Professional Development

• Participate in in-service training programs, in-house activities, conferences, and other assigned programs.
• Develop thorough understanding of hospital policies and procedures and demonstrate compliance.
• Maintain patient and organizational confidentiality as per signed agreements.
• Perform additional duties as assigned by the Head of Department.

Qualifications & Experience

• Graduate degree in Allied Health Sciences or a related field.
• Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA).
• Minimum of two years of professional coding experience.

Skills & Competencies

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