Clinical Coder

The Clinical Coder is responsible for performing accurate and timely ICD10-AM and DRG coding for all inpatient and day surgery cases, ensuring high-quality data submission to the Ministry of Health (MOH).

MAJOR DUTIES AND RESPONSIBILITIES

1) Clinical Coding Operations 

• Execute comprehensive ICD10-AM and DRG coding for all inpatient discharges and day surgery procedures in accordance with national coding standards
• Interpret complex clinical data and medical documentation to generate precise DRG codes
• Monitor uncoded cases list and coordinate with Medical Records Office staff regarding outstanding Hospital Inpatient Discharge Summaries
• Initiate follow-up actions for unsummarised cases exceeding 72 hours post-discharge
• Maintain strict adherence to patient confidentiality protocols and data security measures

2) Professional Communication and Collaboration 

• Liaise with healthcare professionals to clarify clinical documentation
• Engage with relevant stakeholders to resolve coding queries and documentation gaps
• Participate in coding quality improvement initiatives
• Contribute to departmental coding standards and guidelines

3) Administrative Duties 

• Maintain accurate coding records and documentation
• Undertake additional projects and duties as assigned by supervision/HOD

JOB REQUIREMENTS

Essential Skills and Competencies

• Comprehensive knowledge of medical terminology and anatomy
• Strong understanding of healthcare documentation and clinical workflows
• Exceptional attention to detail and analytical capabilities
• Proficient in relevant coding software and healthcare information systems
• Excellent written and verbal communication skills
• Good time management and organisational abilities

Technical Knowledge Requirements

• In-depth understanding of ICD10-AM coding conventions and standards
• Proficiency in DRG grouping methodologies
• Knowledge of healthcare compliance and privacy regulations
• Familiarity with medical records management systems

Key Performance Indicators

• Coding accuracy rates
• Timeliness of coding completion
• Quality of documentation queries
• Adherence to confidentiality protocols
• Contribution to departmental objectives

Required Qualifications

• Diploma/Degree in Health Information Management or equivalent qualification
• Certification in Clinical Coding
• Demonstrated proficiency in ICD10-AM and DRG coding systems
• Minimum 2 years of clinical coding experience in a healthcare setting