IP Medical Coder

Role Overview

IP Medical Coder at NMC Healthcare, based at NMC Healthcare.

Role Purpose

The incumbent checks and sequences the most accurate ICD-9/ICD-10-CM/CPT/HCPCS/DRG and other codes for diagnoses and procedures based on documented information, ensuring final diagnoses and operative procedures stated by the physician are valid and complete.

Key Responsibilities

Clinical Coding

• Assign accurate ICD-9-CM, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
• Validate that final diagnoses and operative procedures documented by physicians are complete and accurately coded.
• Abstract relevant information from health records to identify secondary diagnoses, complications, and co-morbidities.
• Ensure the final diagnosis reflects the care and treatment provided and assign the correct DRG for all inpatient cases.

Documentation Review

• Review medical records for documentation consistency, completeness, and adequacy.
• Analyze physicians' documentation to ensure accurate assignment of Evaluation & Management (E&M) levels using the appropriate CPT codes.
• Provide constructive feedback to physicians regarding coding discrepancies, documentation gaps, and missed coding opportunities.

Compliance & Governance

• Ensure compliance with DOH (formerly HAAD) coding guidelines, regulations, and coding standards.

Training & Development

• Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians on coding practices and regulatory updates.

Qualifications & Experience

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

Skills & Competencies

• Proficient in MS Office and general computer applications.
• Excellent written and verbal communication skills in English.
• Achieve assigned objectives in line with organizational and stakeholder expectations.
• Demonstrate professionalism and collaborate effectively with multidisciplinary teams.
• Manage multiple tasks efficiently, adapt to changing priorities, and meet deadlines.
• Willingness to attend meetings outside normal working hours when required.