Medical Coder

Job Description

• Checks and sequences the most accurate ICD-9-CM / CPT / HCPCS / DRG / other codes for diagnoses and procedures based on documented information.
• Assures that the final diagnoses and operative procedures stated by the physician are valid and complete.
• Prepares daily and monthly coding audit reports.
• Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
• Evaluates records for documentation consistency and adequacy, ensuring that the final diagnosis accurately reflects the care and treatment rendered.
• Ensures coding is as per DOH guidelines and regulations.
• Provides feedback to doctors regarding coding errors or oversights.
• Stays updated with the latest coding versions and DOH coding directives.
• Maintains inter- and intradepartmental communication for the smooth functioning of the department.
• Strictly adheres to organizational regulations and policies, especially those related to infection control, patient safety, ADOSH, DOH, JCI, and ISO.
• Supports Continuous Quality Improvement and actively participates in quality assurance activities of the service.
• Participates and contributes in scheduled in-service training programs, in-house activities, conferences, or other programs as requested.
• Maintains confidentiality as per the agreement signed.
• Demonstrates active listening to promote effective communication.
• Develops a thorough understanding of hospital policies and procedures and demonstrates respect for them.
• Carries out other duties as requested by the Head of Department.