OP Medical Coder

Role Overview

OP Medical Coder at NMC Healthcare. The role ensures proper coding of documents in accordance with regulator coding guidelines and regulations.

Role Purpose

To assign accurate clinical codes and validate physician documentation for diagnoses and procedures, ensuring compliance with coding standards, regulatory requirements, and organizational policies while supporting the coding team through mentorship and continuous standards improvement.

Key Responsibilities

Coding & Classification

• Assign accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
• Compute and assign the appropriate Diagnosis Related Group (DRG) for all inpatient cases.
• Review physician documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.

Clinical Documentation Review

• Abstract relevant clinical information from health records, including secondary diagnoses, complications, and co-morbid conditions.
• Review medical records for documentation consistency, completeness, and adequacy to ensure accurate representation of patient care.
• Validate that final diagnoses and operative procedures documented by physicians are complete, accurate, and compliant with coding standards.
• Provide constructive feedback to physicians regarding coding discrepancies, documentation deficiencies, and missed coding opportunities.

Compliance & Governance

• Ensure coding compliance with applicable HAAD/DOH coding guidelines, regulations, and organizational policies.
• Stay current with the latest coding classifications, coding updates, and DOH/HAAD coding directives.

Team Leadership & Development

• Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians, including updates on new coding guidelines and regulatory changes.

Occupational Safety & Health

• Comply with all Occupational Safety & Health (OSH) and Infection Control policies, standards, and procedures.
• Perform duties in accordance with documented OSH policies, procedures, and assigned responsibilities.
• Be familiar with emergency response and evacuation procedures.
• Report OSH hazards, incidents, near misses, and unsafe conditions, and assist in risk assessments and incident investigations.
• Comply with hospital waste management policies and procedures.
• Attend mandatory OSH, Infection Control, safety awareness programs, and emergency and mock drills.
• Use appropriate Personal Protective Equipment (PPE) and follow all applicable safety protocols.

General Duties

• Perform miscellaneous duties and special projects as assigned.
• Carry out any additional responsibilities assigned by the Head of Department (HOD) within the scope of the role.

Qualifications & Experience

• Bachelor's Degree in Allied Health Sciences or related areas.
• At least two (2) years of coding experience.
• Valid Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification from the American Academy of Professional Coders (AAPC).

Skills & Competencies

• Computer literacy and MS Office proficiency.
• Excellent command of oral and written English.
• Ability to coordinate multiple tasks, adjust to changing priorities, and work within deadlines.
• Ability to work constructively and interact professionally with others.

Additional Information

• Achievement of Core Objectives in line with the expectations of Management and stakeholders is a performance criterion for the role.