EXECUTIVE, HEALTH INFORMATION MANAGEMENT SERVICES

Tawakkal Specialist Hospital; Kuala Lumpur; On-site; MYR 42,000 - 66,000; Full time

Job summary

KPJ Healthcare Berhad seeks a Healthcare ICD Coder to ensure accurate ICD-10/ICD-11 coding for inpatient records and timely reporting. You will review medical records, perform coding audits, and support MOH submissions with precision and confidentiality.

The role requires a healthcare management background, relevant coding credentials, and 1–2 years of experience in a hospital setting. Familiarity with PDPA, HIMS/HIS systems, and reporting standards is essential.

Qualifications

• Diploma in healthcare management or bachelor’s degree in health administration or related qualifications.
• Certified Clinical Coder or equivalent credential preferred.
• 1–2 years of coding experience recommended; fresh graduates may be considered.
• Knowledge of PDPA and ICD-10 & ICD-11.
• Familiarity with HIMS / HIS and electronic medical records.

Responsibilities

• Assist in checking return of medical record folders and ensure accurate documentation and tracking.
• Assign ICD and external cause codes / procedure codes for inpatients based on discharge diagnoses.
• Conduct coding audits to ensure accuracy and consistency per standards.
• Review medical records, discharge summaries, and related documentation for completeness.
• Prepare and submit monthly E-Reporting and SMRP data to MOH and related bodies within deadlines.

Skills

Analytical skills

Detail-oriented

Excel

PowerPoint

Independent worker

Education

Diploma in healthcare management

Bachelor's degree in health administration

Tools

Microsoft Excel

PowerPoint

Job description

General Description

To ensure accurate and timely coding of diagnoses and procedures using ICD 10 / ICD 11 standards international guidelines, submission of reporting and ensure the maintenance of patient confidentiality and delivery of excellent service in accordance with accepted professional standards set by the hospital and government legislation.

Job Description

• Assist in checking return of medical record folders from wards and movements are accurately documented and tracked.
• 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 and SMRP data to the Ministry of Health (MOH), mortality statistics to Group Clinical, KPJHQ and hospital management 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.

Job Requirements

• Education: Diploma in healthcare management or bachelor's degree in health administration or other relevant qualifications.
• Certified Clinical Coder or equivalent credential preferred.
• Knowledge and Experiences: Minimum 1-2 years of coding experience (fresh graduates may be considered).
• Knowledge of PDPA and International Classification Diseases (ICD 10 & ICD 11)
• Familiarity working in HIMS / medical records
• Experience of electronic medical records / hospital information system (HIS).

Skills & Competencies

• Special skills required Strong analytical and problem-solving skills.
• 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.
• Self-motivated and able to work independently.
• Strong ethics and integrity.
• Openness to learning and adapting to change.
• A collaborative and team-oriented approach.

KPJ Healthcare Berhad is founded on the vision of being the preferred healthcare provider in the region. We are focused on delivering world-class quality healthcare services throughout our regional footprint across 5 countries, namely Malaysia, Indonesia, Thailand, Bangladesh, and Australia. We are in search of remarkable people to join us in exploring and discovering better healthcare solutions together. Whether you are a student, a graduate, or an experienced professional, discover the impact you could make with a career at KPJ.