OP Medical Coder

Job Description

• Checks and sequences accurate ICD-9-CM, CPT, HCPCS, DRG, and other relevant codes for diagnoses and procedures.
• Ensures final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
• Prepares daily and monthly coding audit reports.
• Abstracts necessary information from medical records to identify secondary complications and co-morbid conditions.
• Evaluates records for documentation consistency, adequacy, and accuracy, ensuring diagnoses reflect the care and treatment provided.
• Ensures coding is compliant with DOH guidelines and regulations.
• Provides feedback to physicians regarding coding errors or documentation oversights.
• Keeps updated with latest coding versions and DOH coding directives.
• Maintains effective intra- and inter-departmental communication for smooth department functioning.
• Adheres strictly to organizational policies, especially regarding infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.
• Supports Continuous Quality Improvement (CQI) initiatives and contributes to all quality assurance activities.
• Participates in in-service training programs, in-house activities, conferences, and other assigned programs.
• Maintains confidentiality in accordance with signed agreements.
• Demonstrates effective listening and communication skills to promote collaboration.
• Develops thorough understanding of hospital policies and procedures and shows respect for them.
• Performs additional duties as assigned by the Head of Department.