1. Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations. 

   
   

• Assign accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
• Validate that final diagnoses and operative procedures documented by physicians are complete, accurate, and compliant with coding standards.
• 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.
• Compute and assign the appropriate Diagnosis Related Group (DRG) for all inpatient cases.
• Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians, including updates on new coding guidelines and regulatory changes.
• Review physician documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.
• Ensure coding compliance with applicable HAAD/DOH coding guidelines, regulations, and organizational policies.
• Provide constructive feedback to physicians regarding coding discrepancies, documentation deficiencies, and missed coding opportunities.
• Stay current with the latest coding classifications, coding updates, and DOH/HAAD coding directives.
• 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.

Occupational Safety & Health (OSH) and Infection Control Responsibilities

• 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/mock drills.
• Use appropriate Personal Protective Equipment (PPE) and follow all applicable safety protocols.

• A graduate of Bachelor's Degree in Allied Health Sciences or related areas with 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).
• Computer Literacy, MS Office.
• Excellent command of oral and written English.

• Achievement of Core Objectives in line with the expectations of the Management and stakeholders.
• Ability to work constructively and interact professionally with others.
• Ability to coordinate multiple tasks, adjust to changing priorities, and work within deadlines.