OP Medical Coder

Job Description

• Reviews and sequences accurate ICD-9-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on documented clinical information.
• Ensures that final diagnoses and operative procedures documented by physicians are valid, complete, and compliant.
• Prepares daily and monthly coding audit reports.
• Abstracts all required information from medical records to identify secondary complications and co-morbid conditions.
• Evaluates medical records for documentation consistency, completeness, and adequacy, ensuring diagnoses accurately reflect the care and treatment provided.
• Ensures coding compliance with DOH guidelines, standards, and regulatory requirements.
• Provides timely and constructive feedback to physicians regarding coding errors, omissions, or documentation gaps.
• Remains updated with current coding systems, revisions, and DOH coding directives.
• Maintains effective intra- and inter-departmental communication to ensure smooth departmental operations.
• Strictly adheres to organizational policies and procedures, particularly those related to infection control, patient safety, ADOSH, DOH, JCI, and ISO standards.
• Supports Continuous Quality Improvement (CQI) initiatives and actively participates in all quality assurance activities.
• Participates in scheduled in-service training programs, in-house activities, conferences, and other assigned educational programs.
• Maintains confidentiality in accordance with signed agreements and organizational policies.
• Demonstrates effective listening and communication skills to promote collaboration and teamwork.
• Develops a thorough understanding of hospital policies and procedures and demonstrates compliance at all times.
• Performs additional duties as assigned by the Head of Department.