Role & responsibilities : 1. Management of Medical Records Maintain and manage patient medical records ensuring accuracy, completeness, and confidentiality. Organize and file medical records systematically for easy retrieval. Ensure all medical records are updated timely with relevant clinical notes, reports, test results, and discharge summaries. Manage both paper-based and electronic health records (EHRs) efficiently. 2. Coding and Classification Supervise or assist with medical coding (ICD-11, CPT) to classify diagnoses and procedures accurately. Ensure coding aligns with hospital billing and insurance requirements . Coordinate with the billing and insurance departments to resolve discrepancies related to coding. 3. Data Accuracy and Quality Control Conduct periodic audits of medical records to maintain data integrity and compliance with regulatory standards (NABH, ISO, JCI). Identify and rectify errors, missing information, or discrepancies in patient files. Ensure compliance with legal and ethical standards governing patient data privacy (e.g., HIPAA-like rules). 4. Reporting & Documentation Prepare and submit periodic reports on medical records activities to hospital administration. Provide statistical data and analysis related to patient admissions, discharges, morbidity, and mortality for research and management purposes. Maintain records of medical records personnel attendance, performance, and training. 5. Supervision and Training Supervise Medical Records Department (MRD) staff including coders, record technicians, and clerks. Conduct or arrange training programs to update staff on new coding standards, software, and regulatory changes. Ensure smooth workflow and task delegation in the MRD. 6. Coordination Coordinate with clinical departments, nursing, billing, and IT teams for smooth exchange of medical information. Support medical audit and research activities by providing required data and documentation. Liaise with external bodies for compliance, accreditation, and legal matters related to medical records. 7. System Maintenance and Upgradation Assist in implementing and upgrading Hospital Information Systems (HIS) and Electronic Medical Records (EMR) systems. Facilitate smooth migration of paper records to digital formats when applicable. Ensure backup and disaster recovery procedures for medical records. 8. Compliance and Confidentiality Maintain strict confidentiality and safeguard patient privacy at all times. Ensure adherence to hospital policies and governmental laws related to health information management.
Role & responsibilities : 1. Medical Coding of Diagnoses & Procedures Assign appropriate ICD-11 (International Classification of Diseases) codes for all diagnoses, diseases, and conditions mentioned in patient records. Apply CPT/HCPCS codes for medical procedures, surgeries, and treatments. Ensure accurate coding for inpatient, outpatient, emergency, and specialty departments . 2. Review of Clinical Documentation Examine patient files including discharge summaries, physician notes, lab reports, radiology, and operative notes to extract relevant clinical data. Identify missing or unclear documentation and query physicians or clinicians for clarification. Ensure that documentation supports the codes assigned and is complete and accurate . 3. Data Accuracy & Compliance Ensure all coding complies with national and international coding standards . Adhere to regulatory norms set by NABH, JCI, or ISO , and hospital-specific policies. Maintain updated knowledge of ICD revisions, coding guidelines, and payer-specific requirements . 4. Billing and Reimbursement Support Work with the billing department to ensure that coding supports appropriate claims processing and reimbursement. Help resolve claim denials or rejections related to coding errors or discrepancies. Participate in coding audits to verify billing integrity and reduce revenue loss. 5. Data Reporting & Analysis Contribute to generating morbidity, mortality, disease surveillance , and other epidemiological reports. Assist in data abstraction for medical research, performance indicators, and public health reporting. Provide coded data for medical audits, clinical research, and hospital statistics. 6. Coordination and Communication Coordinate with physicians, medical records officers, nurses, billing teams , and hospital IT. Escalate documentation issues and work collaboratively to improve data quality. Participate in meetings and training related to coding updates or compliance. 7. Confidentiality and Record Security Maintain strict confidentiality of patient health information (PHI). Adhere to data protection regulations and institutional privacy standards. Prevent unauthorized access or disclosure of medical records.