Medical Coder

DUTIES AND RESPONSIBILITIES

• The incumbent checks and sequences the most accurate ICD-9/ ICD10-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.

• Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.

• Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Computes and gives the correct DRG coding all inpatients cases.

• Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

• Analyzes doctors’ documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.

• Ensures coding is as per HAAD guidelines and regulations.

• Provides feedback to Doctors regarding coding errors or oversights.

• Constantly updates to the latest coding versions and HAAD coding directives.

• Performs miscellaneous job-related duties as assigned.

• Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

OHS ROLES & RESPONSIBILITIES:

• Responsible to be familiarize, comply and implement the OSHAD-SF& NMCSH Al Ain Internal OSHMS policies and procedures/SOP’s relevant to their department.

• Staff should notify/report all OSHMS hazards, incidents, accidents and near misses within the premises of NMCSH Al Ain to their supervisor or department OSH Facilitator as per the incident reporting protocol of NMCSH Al Ain.

• Staff are responsible to assist with the preparation of departmental risk assessment activities and implement the control measure within the timeframe.

• Staff are responsible to attend applicable department OSHMS training.

• Staff are not allowed to tamper or misuse any NMCSH Al Ain equipment’s and its property.3.13 Comply with all OSH instructions, safe working procedures and signages within the premises of NMCSH-Al Ain.

• Be familiar with emergency and evacuation procedure.

• Not willfully or recklessly endanger anyone's health and safety;

• Make proper use of all machinery, tools, substances, etc., safety systems and of all Personal Protective Equipment provided for use at work.

• Participate in required OSH inspection, audit and OSH monitoring programs.

Additional duties/responsibilities (related to ADHICS) assigned to this position in clear, concise language:

Health Information Literacy and Skills:

• Adhere to information systems policies and procedures as required by Health Care Organization.

• Privacy, Confidentiality of Health Information:

• Follow security and privacy policies and procedures to the use of networks, including intranet and Internet.
• Follow confidentiality and security measures to protect electronic health information.
• Maintain data integrity and validity within an information system.
• Report any possible breaches of confidentiality in accordance with organizational policies.

Health Information/Data Technical Security:

• Apply departmental and organizational data and information system security policies

• Basic Computer Literacy Skills:

• Use basic word processing, spreadsheet and desktop presentation applications as applicable to your work.
• Demonstrate proficiency in Windows operating environment.
• Demonstrate use of email, addressing, forwarding, attachments, netiquette

DUTIES AND RESPONSIBILITIES

• The incumbent checks and sequences the most accurate ICD-9/ ICD10-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.

• Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.

• Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Computes and gives the correct DRG coding all inpatients cases.

• Providing training and guiding other coders / Medical Records Technicians in coding, updating them with new coding rules and regulations as and when it is necessary.

• Analyzes doctors’ documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.

• Ensures coding is as per HAAD guidelines and regulations.

• Provides feedback to Doctors regarding coding errors or oversights.

• Constantly updates to the latest coding versions and HAAD coding directives.

• Performs miscellaneous job-related duties as assigned.

• Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

OHS ROLES & RESPONSIBILITIES:

• Responsible to be familiarize, comply and implement the OSHAD-SF& NMCSH Al Ain Internal OSHMS policies and procedures/SOP’s relevant to their department.

• Staff should notify/report all OSHMS hazards, incidents, accidents and near misses within the premises of NMCSH Al Ain to their supervisor or department OSH Facilitator as per the incident reporting protocol of NMCSH Al Ain.

• Staff are responsible to assist with the preparation of departmental risk assessment activities and implement the control measure within the timeframe.

• Staff are responsible to attend applicable department OSHMS training.

• Staff are not allowed to tamper or misuse any NMCSH Al Ain equipment’s and its property.3.13 Comply with all OSH instructions, safe working procedures and signages within the premises of NMCSH-Al Ain.

• Be familiar with emergency and evacuation procedure.

• Not willfully or recklessly endanger anyone's health and safety;

• Make proper use of all machinery, tools, substances, etc., safety systems and of all Personal Protective Equipment provided for use at work.

• Participate in required OSH inspection, audit and OSH monitoring programs.

Additional duties/responsibilities (related to ADHICS) assigned to this position in clear, concise language:

Health Information Literacy and Skills:

• Adhere to information systems policies and procedures as required by Health Care Organization.

• Privacy, Confidentiality of Health Information:

• Follow security and privacy policies and procedures to the use of networks, including intranet and Internet.
• Follow confidentiality and security measures to protect electronic health information.
• Maintain data integrity and validity within an information system.
• Report any possible breaches of confidentiality in accordance with organizational policies.

Health Information/Data Technical Security:

• Apply departmental and organizational data and information system security policies

• Basic Computer Literacy Skills:

• Use basic word processing, spreadsheet and desktop presentation applications as applicable to your work.
• Demonstrate proficiency in Windows operating environment.
• Demonstrate use of email, addressing, forwarding, attachments, netiquette

QUALIFICATION, LICENSURE, EDUCATION, EXPERIENCE, SPECIAL SKILLS :

• A graduate of Bachelor’s Degree in Allied Health Sciences or related areas with at least two (2) years of coding experience with valid Certified Coding Associate(CCA) certification from American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification from American Academy of Professional Coders (AAPC).

• Computer Literacy, MS Office.

• Excellent command of oral and written English.

• Performance Criteria:

• 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 task, adjust to changing priorities and work within deadlines.
• Ability to attend to meetings outside of normal business hours