Reviews medical records documented by physicians, nurses, and other clinical staff and ensures all medical records are in place with no missing documentation.
Validates physicians’ clinical documentation data quality and provides documentation tips/training to concerned staff for improved reporting to senior management.
Provides data to authorized personnel for studies and/or research purposes.
Assists in external medical audits by coordinating with the auditors and providing access to the required medical records.
Performs periodic internal audits to improve and sustain quality levels and compliance.
The incumbent checks and sequences the most accurate ICD10-CM/CPT/HCPCS/DRG/Other codes for diagnoses and procedures for documented information.
Assures the final diagnoses and operative procedures 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 for all inpatient cases.
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for resubmission purposes.
Ensures coding as per DOH/DHA guidelines and regulations.
Performs any other duty as required by the line manager or supervisor that is commensurate with the post.
Qualifications
Education
Bachelor’s Degree in Health Information Management or any relevant fields
Experience
Minimum 4-5 years of progressive career experience
Relevant experience in a hospital/medical center environment within UAE
Certification and Licensure
Coding certificate by AAPC / AHIMA
Job Specific Skills and Abilities
Knowledgeable of DOH/DHA and HIPAA rules and regulations