EXECUTIVE, HEALTH INFORMATION MANAGEMENT SYSTEM

DAMANSARA SPECIALIST HOSPITAL 2; Petaling Jaya; On-site; MYR 30,000 - 45,000; Full time

Job summary

DAMANSARA SPECIALIST HOSPITAL 2 is seeking a dedicated individual to manage medical records and ensure accuracy in documentation and coding. Responsibilities include auditing medical records, submitting reports to the Ministry of Health, and liaising with medical practitioners.

The ideal candidate will have relevant qualifications and experience, familiarity with HIS, and a detail-oriented mindset. Strong skills in Microsoft Excel and PowerPoint are required. Join us in upholding our high standards of healthcare documentation and patient care.

Qualifications

• At least 1-5 years of experience from any established medical organization.
• Familiarity working in Hospital Information Management Systems (HIMS) or medical records.
• Basic IT knowledge for Hospital Information System (HIS) use.

Responsibilities

• Assist in checking and filing medical record notes accurately.
• Manage medical report assignments and ensure coding accuracy.
• Conduct administrative audits and submit data to the Ministry of Health.

Skills

Detail-oriented

Proficiency in Microsoft Excel

Proficiency in PowerPoint

Results-oriented mindset

Collaborative approach

Education

Diploma, Degree or relevant qualifications

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

Requirements

• Education: Diploma, Degree or other relevant qualifications.
• 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.
• 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.