Job Title:  Medical Records Technician

Job Summary

1. Responsible for assigning accurate codes to patient records based on diagnosis, procedures and treatments.
2. Ensure proper documentation for billing, compliance and statistical analysis contributing to the efficient functioning of healthcare facilities.

Principles Duties and Responsibilities

Medical Coding:

1. Assign appropriate ICD-10-CM and ICD-10-PCS codes to diagnoses and procedures.
2. Ensure accuracy and correct sequencing of medical codes.
3. Advise and train staff on medical coding practices within the Coding Unit.
4. Assist with Coding Unit audits to ensure accuracy and compliance.

Patient Record Management:

1. Assist in the development of a Personal Health Folder for patients.
2. Actively participate in the computerization of medical records, including the long-term development of the electronic medical record (EMR).
3. Assist and carry out the disposal of medical records following the policy and process.
4. Ensure that the disposal of medical records is conducted as needed and complies with organizational policies.
5. Undertake quality audits on medical records and contribute to related quality improvement projects

Policy Compliance and Implementation:

1. Ensure the implementation and compliance of all JPMC and departmental policies and procedures.
2. Recommend, implement, and maintain policies and procedures for the Medical Records Department.
3. Assist in the development of hospital policies and procedures related to medical records.
4. Plan and develop medical records standards to meet the organisation’s mission and vision, including related accrediting standards.

Other Duties:

1. Perform other duties as required or assigned to support departmental operations.

Professional Requirements

Minimum five (5) years’ experience in a clinical or hospital setting​​​​​​​

Educational Requirements

1. At least a Higher National Diploma (HND) in Health Information Management (HIM), Nursing, Public Health, Clinical, Mathematics, Statistics or related similar from an institute recognized by the Government of His Majesty of Negara Brunei Darussalam is required.
2. Certification in Clinical Coding i.e Certified Professional Coder, Certified Outpatient Coding, Certified Inpatient Coder, Certified Clinical Coder is highly desirable

Specialised Skills/Knowledge/Attribute Requirement

1. In-depth knowledge of Medical Records and Medical Coding techniques, policies, standards, and procedures.
2. Proficient in diagnostic coding procedures, particularly in the current volume of major internationally recognised classification diseases ICD-10-CM and ICD-10-PCS.
3. Fluent in oral and written English.
4. Effective interpersonal communication skills are desirable.
5. Capacity to drive hospital accreditation activities