Job Description
Job Purpose :
The clinical coder is responsible for translating the narrative descriptions of diseases, injuries, other health related problems, and procedures into alphanumeric and numeric codes using ICD-10-AM/ACHI/ACS.
Key Accountabilities & Responsibilities:
- Read and analyze the patient’s record to abstract all possible diagnoses and interventions relevant to the current episode of care.
- Allocate codes to the current episode of care, using knowledge of the information contained within the ICD-10-AM and ACHI. International Classification of Diseases, 10th Revision, Australian Modification, commonly referred to as ICD-10-AM and Australian Classification of Health Intervention (ACHI).
- Utilize the 3M Code Finder software, relevant patient information systems, and related pathology and associated databases to assist in verification and allocation of clinical codes.
- Interact with clinicians to clarify documentation in specific patients’ records, in order to assign codes in a timely and accurate manner using coder-clinician communication query form.
- Assess the patient’s record content and bring any concerns about the accuracy, consistency, or ethics of the documentation to the attention of management.
- Assist with the education of clinicians with regard to ICD-10-AM.
- Initiate, participate in, and contribute to quality improvement and education activities and initiatives.
- Maintain strict confidentiality about patient’s record.
- Act in a manner congruent with the maintenance of a safe and harmonious workplace.
- Follow all applicable policies and procedures.
- Respects patients and their families to promote a patient-centered care culture.
- Participates in and supports quality improvement and patient safety activities as an individual or as part of a multidisciplinary team.
Perform other duties related to the job as required.
Qualification and Experience
Minimum or Required: 2 Years Diploma in Health Information Management, Health Information System, or any related field.
- SCHS Registration/License in Medical Coding.
Or
- Bachelor Degree in Science or English + 1 year diploma in Medical Coding.
SCHS Registration/License in Medical Coding.
- 2 years of Experience.
Preferred: HIMAA ICD-10-AM Intermediate Course
