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Major Group
3
Technicians and Associate Professionals
Sub-Major Group
32
Health Associate Professionals
Minor Group
325
Other Health Associate Professionals
Minor Unit Group
MASCO Code
3252-01
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Clinical Coder
Clinical Coder reviews, analyses, and manages a patient’s medical record and clinical documentation to assign standardised codes, ensuring the accuracy and completeness of diagnoses, treatment plans, and test results. They facilitate proper billing, research, and compliance with healthcare regulations, working closely with a medical professional to clarify inconsistencies and maintain a high-quality record. Their work supports the integrity of healthcare data and the efficient operation of a medical service.
Tasks
Assign standardised diagnostic and procedure codes to patient records based on clinical documentation.
Ensure accuracy and compliance with coding and classification systems.
Review medical charts, discharge summaries, and surgical notes to ensure completeness and clarity for coding purposes.
Collaborate with healthcare professionals to obtain clinical clarification of patient records.
Prepare coded data for billing, insurance claims, and healthcare reporting purposes.
Collect, organise, and process medical records and related clinical documentation.
Maintain confidentiality and ensure security of patient medical records and health information.
Conduct clinical coding audits and participate in quality assurance activities.
Skills
Basic
Analytical thinking and problem-solving skills.
Attention to detail and accuracy in documentation and data management.
Effective communication and interpersonal skills for liaising with clinicians and colleagues.
Proficiency with computer applications and health information systems.
Strong understanding of medical terminology, anatomy, physiology, and clinical procedures.
Specific
Competency in conducting clinical coding audits and participating in coder training activities.
Competency in interpreting clinical documentation and narratives according to coding guidelines.
Competency in maintaining confidentiality and ensuring data security of patient records.
Competency in managing and maintaining accurate medical records.
Competency in supporting health information reporting and compliance activities.
Familiarity with Electronic Medical Records (EMR) and health informatics systems.
Knowledge in local and international coding standards and regulatory requirements.
Knowledge in medical terminology and healthcare documentation standards.
Proficiency in various coding systems.
Additional Info
QUALIFICATION
Diploma or equivalent
Related Courses
Minor Unit Group
3252-01
Clinical Coder
MASCO
Hi, I can assist you with questions related to the Malaysia Standard Classification of Occupations (MASCO).
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