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Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.
Checks and sequences the most accurate ICD-9/ICD-10-CM/CPT/HCPCS/DRG/other codes for diagnoses and procedures based on documented information, ensuring final diagnoses and operative procedures stated by the physician are valid and complete.
Abstracts necessary information from health records to identify secondary complications and co-morbid conditions.
Evaluates records for documentation consistency and adequacy; ensures the final diagnosis reflects the care provided; computes and assigns the correct DRG for all inpatient cases.
Provides training and guidance to other coders/medical records technicians, including updates on new coding rules and regulations.
Analyzes physicians’ documentation to ensure appropriate E&M levels and correct CPT codes are assigned.
Ensures coding compliance with HAAD guidelines and regulations.
Provides feedback to doctors regarding coding errors or oversights.
Keeps updated with the latest coding versions and HAAD coding directives.
Performs miscellaneous job-related duties as assigned.
Performs any other tasks assigned by the HOD within the scope of the job title.
Complies with all OSH and infection control policies, standards, and procedures; cooperates with hospital management to meet compliance requirements.
Works in accordance with documented OSH procedures and instructions.
Is familiar with emergency and evacuation procedures.
Reports OSH hazards, incidents, near misses, and assists with risk assessments and incident reports.
Complies with waste-management procedures and policies.
Attends applicable OSH/Infection Control training programs, mock drills, and awareness programs.
Uses appropriate personal protective equipment (PPE) and safety systems as required.
Bachelor’s Degree in Allied Health Sciences or a related field, with at least two (2) years of coding experience.
Valid Certified Coding Associate (CCA) certification from AHIMA or Certified Professional Coder (CPC) certification from AAPC.
Computer literacy, including proficiency in MS Office.
Excellent command of oral and written English.
Performance Criteria:
Achievement of core objectives in alignment with management and stakeholder expectations.
Ability to work constructively and interact professionally with colleagues and other stakeholders.
Ability to coordinate multiple tasks, adapt to changing priorities, and meet deadlines.
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