OP Medical Coder

Role Overview

Medical Coder at NMC Healthcare. The role ensures accurate and compliant medical coding for diagnoses and procedures across the organization.

Role Purpose

To review clinical documentation, assign the most accurate medical codes according to established standards and regulatory requirements, and maintain the integrity of coded health records through rigorous quality assurance and compliance monitoring.

Key Responsibilities

Coding & Classification

• Check and sequence the most accurate ICD-9-CM, CPT, HCPCS, DRG, and other codes for diagnoses and procedures based on documented information.
• Ensure final diagnoses and operative procedures stated by the physician are valid and complete.
• Abstract necessary information from health records to identify secondary complications and co-morbid conditions.

Documentation & Validation

• Evaluate records for documentation consistency and adequacy.
• Ensure final diagnosis accurately reflects the care and treatment provided.
• Provide feedback to doctors regarding coding errors or oversights.

Compliance & Regulatory

• Ensure coding compliance with DOH guidelines and regulations.
• Keep updated with the latest coding versions and DOH directives.
• Adhere strictly to organizational policies, including infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.

Reporting & Quality

• Prepare daily and monthly coding audit reports.
• Support continuous quality improvement and participate in quality assurance activities.

Communication & Collaboration

• Maintain interdepartmental communication for smooth department functioning.
• Demonstrate effective communication and active listening skills.
• Develop thorough understanding of hospital policies and procedures and adhere to them.

Additional Duties

• Participate in training programs, in-house activities, conferences, and other assigned programs.
• Perform additional duties as assigned by the Head of Department.

Qualifications & Experience

• Graduate in Allied Health Sciences or a related field.
• Certified Coding Associate (CCA) from AHIMA.
• Minimum 2 years of coding experience.

Skills & Competencies

• Computer literacy.
• Excellent command of spoken and written English.
• Active listening and effective communication.
• Maintains confidentiality as per the signed agreement.