OP Medical Coder

Role Overview

OP Medical Coder at NMC Healthcare. The incumbent performs medical coding duties including the review, sequencing, and validation of diagnostic and procedural codes.

Role Purpose

To ensure accurate and compliant medical coding of patient diagnoses and procedures based on documented clinical information, maintaining compliance with regulatory guidelines while supporting quality assurance and departmental operations.

Key Responsibilities

Coding Review & Validation

• Review and sequence accurate ICD-9-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information.
• Assure final diagnoses and operative procedures as stated by the physician are valid and complete.
• Ensure coding is as per DOH guidelines and regulations.
• Ensure that final diagnosis accurately reflects the care and treatment rendered.

Medical Record Abstraction & Evaluation

• Abstract all necessary information from health records to identify secondary complications and co-morbid conditions.
• Evaluate the record for documentation consistency and adequacy.
• Evaluate medical records for documentation consistency, completeness, and adequacy, ensuring diagnoses accurately reflect the care and treatment provided.

Reporting & Audit

• Prepare daily and monthly coding audit reports.

Compliance & Quality Assurance

• Ensure coding compliance with DOH guidelines, standards, and regulatory requirements.
• Strictly adhere to organization's regulations and policies especially those related to infection control, patient safety, ADOSH, DOH, JCI and ISO.
• Support Continuous Quality Improvement and participate and contribute to all quality assurance activities of the service.
• Maintain confidentiality as per the agreement signed.

Physician Engagement & Professional Development

• Provide timely and constructive feedback to doctors regarding coding errors or oversights.
• Remain updated with current coding systems, revisions, and DOH coding directives.
• Participate and contribute in scheduled in-service training programs, in-house activities, conferences or other programs as requested.

Communication & Collaboration

• Maintain effective intra- and inter-departmental communication for the smooth functioning of the department.
• Demonstrate the ability to listen to others in promoting effective communication.
• Develop thorough understanding of policies and procedures of the hospital and demonstrate respect for them.

General

• Carry out other duties when requested by the Head of Department.

Qualifications & Experience

• Graduate in Allied Health Sciences or a related field.
• Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA).
• Minimum of two (2) years of coding experience.

Skills & Competencies

• Strong computer literacy.
• Excellent oral and written English communication skills.
• Effective listening and communication skills to promote collaboration and teamwork.