ASSISTANT, HEALTH INFORMATION MANAGEMENT SERVICES

Job Description

• Assist in checking return of medical record folders from wards and movements are accurately documented and tracked.
• Ensure accuracy in assigning ICD and external cause code / procedure codes for all inpatient cases based on discharge diagnoses, in accordance with ICD regulations for statistical and reporting purposes.
• Ensure the accuracy and consistency of ICD coding by conducting regular cross-checking and coding audits in accordance with established standards and guidelines.
• Review, check, and validate medical records, discharge summaries, and related documentation to ensure accuracy, completeness, and consistency.
• Conduct administrative audits and produce reports on the completeness, legibility, and accuracy of medical record documentation.
• Prepare, organize, and submit monthly E-Reporting and SMRP data to the Ministry of Health (MOH), mortality statistics to Group Clinical, KPJHQ and hospital management within the timelines given.
• Provide and assist in the preparation and submission of coding-related reports, summaries, and analyses for state district center and hospital management use.
• Register and submit cancer cases to the National Cancer Registry in compliance with MOH guidelines and reporting standards (if applicable)
• Gather and distribute reports on notification of infectious diseases to the MOH via email / fax or through the e-Notification system within the stipulated time (if applicable).

Job Requirement

• Diploma in healthcare management or other relevant qualifications.
• Certified Clinical Coder or equivalent credential preferred.