Medical Records jobs

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

• Review and sequence accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG , and other applicable codes for documented diagnoses and procedures.
• Ensure final diagnoses and operative procedures documented by physicians are valid, accurate, and complete.
• Abstract relevant information from medical records to identify secondary complications, co-morbidities, and other reportable conditions.
• Evaluate medical records for documentation consistency, completeness, and adequacy.
• Ensure final diagnoses accurately reflect the care and treatment provided.
• Assign and validate the appropriate DRG codes for all inpatient cases.
• Provide training and guidance to Medical Coders and Medical Records Technicians on coding practices.
• Keep coding staff updated on new coding rules, regulations, and guidelines.
• Review physicians’ documentation to ensure appropriate Evaluation and Management (E&M) levels are assigned using the correct CPT codes.
• Ensure all coding activities comply with applicable HAAD guidelines and regulations .
• Provide feedback to physicians regarding coding errors, documentation gaps, and oversights.
• Stay updated with the latest coding versions, standards, and HAAD coding directives.
• Perform miscellaneous job-related duties as assigned.
• Perform any other duties assigned by the HOD within the scope of the job role.
• Comply with all OSH and infection control policies, standards, and procedures.
• Follow documented OSH procedures, instructions, and assigned responsibilities.
• Maintain familiarity with emergency and evacuation procedures.
• Promptly report OSH hazards, incidents, near misses, and other safety-related issues.
• Assist with the preparation of risk assessments and incident reports.
• Comply with waste management policies and procedures.
• Attend applicable OSH and infection control training programs, mock drills, and awareness programs.
• Ensure appropriate use of personal protective equipment (PPE) and safety systems.

• Bachelor’s Degree in Allied Health Sciences or a related field from a recognized institution.
• Minimum 2 years of Medical Coding experience .
• Valid Certified Coding Associate (CCA) certification from AHIMA or Certified Professional Coder (CPC) certification from AAPC .
• Good computer literacy with proficiency in Microsoft Office applications .
• Excellent command of spoken and written English .
• Achieve core objectives in line with the expectations of management and relevant stakeholders.
• Demonstrate the ability to work constructively and interact professionally with colleagues and stakeholders.
• Ability to coordinate multiple tasks, adapt to changing priorities, and consistently meet deadlines.