EXECUTIVE, HEALTH INFORMATION MANAGEMENT SYSTEM

Job Description:

Main Responsibilities

• Assist in checking return of medical record notes from words and movements are accurately documented and tracked.
• File, arrange, scan, index and maintain returned medical record notes accurately.
• Performed management of medical report.
• 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 or SMRP data to the Ministry of Health (MOH) 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)
• Gather, collect, and dispatch the external form from the nearest JPN branch within the stipulated time.
• Indent and collect the external form from the nearest JPN branch to ensure availability.
• Liaise and communicate with medical practitioners to clarify incomplete, uncertain, or unclear documentation in patient medical records.
• Liaise with Information Technology (IT) services for change request via the system to register new ICD code in the system.

Other Duties and Responsibilities

• Perform any other responsibilities assigned by immediate superior or hospital management.

Requirements:

Education:

• Diploma, Degree or other relevant qualifications.

Knowledge and Experiences:

• Preferably at least 1-5 years of experience from any established medical organization.
• Familiarity working in HIMS / medical records
• Familiarity with filing systems (terminal digit, straight numeric, etc.) preferred.
• Basic IT knowledge for Hospital Information System (HIS) use.

Skills & Competencies:

Special skills required

• Knowledgeable and committed to job responsibilities.
• Detail-oriented with a focus on accuracy.
• Proficiency in Microsoft Excel and PowerPoint.

Personal attributes

• Results-oriented mindset, with the ability to work under pressure to meet deadlines.
• Strong ethics and integrity.
• Openness to learning and adapting to change.
• A collaborative and team-oriented approach.