Senior / Clinical Coder

Broad Function

Responsible for translating narrative descriptions of diseases, injuries, and procedures into codes, based on a pre-defined Casemix classification system.

Main Duties & Responsibilities

• Accurately abstract relevant data and translate the principal diagnosis, secondary diagnoses, and surgery/procedures of all inpatient and day surgery discharges into ICD-10-AM codes from discharge summary/case notes/operation reports/histology reports in accordance with the national and hospital coding standards within the stipulated time frame for DRG and medi-claim coding.
• Interact closely with clinicians for clarifications/confirmation/feedback on documentation of principal diagnosis, secondary diagnosis, and surgery/procedure/treatment if necessary that may affect coding accuracy and correct subvention.
• Keep abreast of latest coding standards and update coding knowledge/coding skills.
• Manage and track daily uncoded/coders workload report.
• Work closely with the supervisor to continuously improve the current work processes in the Clinical Coding office.

Requirements

• Bachelor’s Degree, Diploma in Medical/Nursing/ Health Science or equivalent.
• In-depth knowledge of medical terminology/procedures.
• Relevant ICD coding experience is preferred.
• Meticulous and thorough in reading through clinical documentation.
• Ability to work independently and also in a team.
• A target-oriented team player with initiative and positive work attitude.
• Excellent communication and writing skills.
• Proficient with Microsoft applications.