Medical Coder (HIM)

Major Duties and Responsibilities

• Codes patient medical records using the ICD-10-AM classification system.
• Consults with physician through the Head of HIM when documentation of diagnosis and procedures is illegible, not clinically state or omitted in order to properly assign codes or when proper sequencing of diagnoses and/or procedures is unclear.
• Filing of the coded records and maintains accurate, neat files in a timely manner.
• Merging the double numbered records on the basis of proper and authorized request with coordination of MSD.
• Maintains confidentiality, security and personal privacy of all patient information and files.
• Codes diagnosis/procedure data for both inpatient and out-patient records, company reporting and generates daily reports.
• Verifies the inpatient census report and adjusts accordingly on a daily basis and compiles a daily and monthly report.
• Collection of statistical data from all the clinical departments to compute the statistics
• Data entry in the HIS program for Ministry of Health and save in the disk to present to Ministry of Health through Head of the Department.
• Utilizes the PC for maintaining and compiling of regular statistical reports and graphic presentation, enters the appropriate abstracting data.
• Participates in on-going education program developed by the department, e.g. department policies and procedures, Fire and Safety, Risk Management, Environmental Control.
• Participates in Monthly meeting to ensure that all the staff completing their job description according to the policy and procedure of the department and discussing current issues to keep the quality to the patient care services.
• Performs other applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and abilities.

Reporting to

• Director/Head of Dept.

Qualifications:

• Certified coder

Minimum educational level of an associate degree

Experience:

• Required

At least (2) years coding experience in an acute care hospital setting.

Competencies:

• Fluency in verbal and written English.
• Competent knowledge and understanding of current coding guidelines and principles.
• Ability to understand diverse documentation style and read various diagnostic reports contained in the Medical Record.
• Ability to operate computerized patient information system and the personal computer.
• Exhibits professionalism and excellent interpersonal communication skills.