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.