Senior Certified Coders

Job Summary

Responsible in verifying and correcting the daily census. Prepares daily in-patient and out-patient company reports. Basic level coding/abstracting of Normal newborn, uncomplicated OB, and day surgery.  Analyzes the medical record and assigns codes to classify diagnoses and procedures conversion using the International Classification of Diseases, Clinical Modification for diseases or surgical procedures. Computes health care statistics monthly and yearly (outpatient and inpatient activities). This supports assessment of clinical care and medical research.  Prepares health care statistics and monthly reports and submits to Ministry of Health (Hijjra calendar) and Quality Improvement. Peer review and justification for resource planning and staff/patient flow forecasting, abstracting information from the medical record and entering the information utilizing the computerized medical record coding/abstracting system.

Major Duties and Responsibilities

 

 

• Ensures through his/her actions, either directly or indirectly, that a superior quality of medical treatment, compassion and understanding is given to every patient served at Care Medical Hospital.

 

 

• 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.

 

 

 

 

• 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 monthly reports.

 

 

 

 

• Ensure codes are accurate and sequenced correctly by guidelines.

 

 

• Ensure compliance with medical coding policies and guidelines.

 

 

• Follow up with the supervisor on any documentation that is insufficient or unclear

 

 

 

 

• 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

 

 

• 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.

 

 

 

 

• Quality checking of the coding of the documents done by the associates.

 

 

 

 

• 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.

 

 

• Complies with hospital dress code.

 

 

• Performs other applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and abilities.

 

 

 

 

• Keeping track of the errors and calculating the accuracies of the associates.

 

 

 

Reporting to

 

 

• Director/Head of HIM Dept.

 

 

 

Supervises

 

 

• Clinical coders.

 

 

 

Qualifications:

 

 

• Certified coder

 

 

• Minimum educational level of an associate degree such as:

 

 

 

 

• Bachelor of Science - Biotechnology

 

 

• Bachelor of Science - Microbiology

 

 

 

Experience:

 

 

• Required

 

 

At least (4) years coding experience using ICD Classification System in an acute care hospital setting.

Competencies:

• Fluency in verbal and written English.
• Must possess complete familiarity with required medical record documentation, Medical Terminology, Anatomy, Physiology, Pathology and Health care statistics.
• 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.

• Proficient in reviewing medical records and determining the accuracy and completeness of the document
• A critical thinker who ensures that all coding activities are properly managed as per the scope
• Solves moderately complex problems on their own.
• Should have an ownership mindset with respect to guidance, team support, and maintaining team quality.