Medical Records Executive

Columbia Asia Hospital - Bukit Jalil; Kuala Lumpur; On-site; MYR 90,000 - 130,000; Full time

Job summary

Columbia Asia Hospital - Bukit Jalil seeks an experienced Health Information / Records Management leader to direct department activities, ensure patient data privacy, and oversee coding, documentation, and reporting workflows. The role requires a Bachelor’s degree in Health Information Management or related field, ICD-11 coding experience, and strong management and organizational skills.

Weekend half-day work is expected.

Qualifications

• Bachelor’s degree in health information management or related field.
• Experience with ICD-11 coding and medical terminology.
• Strong management and organizational skills.
• Willing to work Saturdays (Half day).

Responsibilities

• Ensure privacy, safety and security of patient records; release information only to authorized individuals.
• Propose and implement departmental policies and procedures.
• Develop data storage and retrieval systems for medical records.
• Maintain filing, retrieval and tracking of patient records.
• Update inactive records and record in the Inactive Record Book.
• Assist data entry and medical coding; resolve missing information.
• Collaborate with medical staff to ensure smooth completion of records.
• Maintain department equipment and supplies.
• Ensure timely utilization of hospital services for admissions and discharges.
• Process charges and report amendments as needed.
• Oversee hiring, orientation, training and performance reviews for staff.
• Prepare rosters and leave records for Medical Record staff.
• Supervise staff to follow policies and procedures.
• Provide education opportunities and ongoing professional development.
• Direct coding, reimbursement, transcription, and reporting for ICD coding.
• Compile ICD coding for discharge stats and monthly reports.
• Oversee department budget; participate in meetings.
• Maintain death records and related forms.
• Monitor and maintain disease records and regulatory forms.
• Attend trainings to meet department objectives.
• Ensure compliance with statutory requirements and government meetings.
• Perform quality indicators for department as required.
• Perform related duties as requested.

Skills

Interpersonal skills

Communication skills

Management leadership

Organizational skills

Attention to detail

Discretion and ethics

Education

Bachelor’s Degree in Health Information Management/Records Management

ICD-11 Coding experience

Tools

ICD Coding Software

Job description

Position Summary:

Plan, organize and direct the activities, work load and special projects within the Department to meet standards set by Management or other accreditation requirement.

Ensure that patient records are kept secure according to regulatory legislation, to protect patient confidentiality.

Be familiar with software programs used to maintain records, only release medical information according to regulations.

Coordinate department activities and performance improvement.

Duties and Responsibilities:

1. Help to ensure the privacy, safety and security of records, including release of information only to authorized individuals, including clinicians treating the patient, the patient or others as required by law.

2. Propose and recommend departmental policies and procedures where applicable.

3. Implement effective data storage methods and retrieval systems for patient medical records.

4. Ensure proper filing, retrieving and tracking system of the patient medical records.

5. Ensure all active and inactive files are segregated, update computer inactive status and record in Inactive Record Book.

6. Assist to perform data entry, medical coding and resolving missing information in patient records.

7. Work closely with the medical staff to assure the smooth completion of medical records.

8. Assist in the care and maintenance of department equipment and supplies.

9. Help to assure timely utilization of the hospital services to meet the admission and discharge needs of all patients in the most effective manner.

10. Help to process charge of reports such as payment through cheque or bill amended request.

11. Responsible for the hiring, department specific orientation, training and performance review of Assistants working in the department.

12. Prepare roster and maintain leave record for Medical Record staff.

13. Supervise and ensure staff performs their duties in accordance with the hospital and department policies.

14. Provide education opportunities for staff. Demonstrate an ongoing commitment to continuing professional development and education.

15. Direct staff in the areas of coding and reimbursement, transcription, resource utilization, and statistical reporting (ICD Coding) for national healthcare issues, trends and research, release of information and medical filing.

16. Responsible to the abstracting functions reportable to the Regional Chief Executive Officer

(REO)/ Chief Executive Officer (CEO), Management and Ministry of Health.

17. Compile ICD coding for all discharge, monthly mortality and morbidity report, and monthly inpatient returns statistics to the RCEO/CEO and copy to the Ministry of Health.

18. Oversee the budget; participate in management meetings and committees.

* maintain Death Record

* make available Birth and Death Certificate Forms from registration department.

* make available any necessary form from district health office or state health department.

* maintain record of communicable and non-communicable diseases.

20. Attend relevant training and courses to meet own development needs and those of the department in accordance with the hospital's objectives.

21. Observe and be conversant with all statutory requirements, rules and legislation related to the job.

22. As and when required, to attend meeting with Government agencies and department.

23. Perform Quality Indicator for the department as required by Management or accreditation standard.

24. Perform other related duties as arranged or requested by authorized others.

Education and Requirements:

Bachelor’s Degree in Health Information management/records management or a related healthcare field.

Experienced with ICD-11 Coding and medical terminology

Strong management and organizational skills

Willing to work Saturdays (Half day)

Special Demands:

Interpersonal and communication skills.

Possess good managerial and leadership, negotiation, communication and relationship skills and good judgment. Eye for details and accuracy. Trustworthy, ethical and discreet.

Columbia Asia Group of hospitals, established in Malaysia in 1996, is an international healthcare company operating medical facilities in Malaysia, Indonesia, and Vietnam. Columbia Asia hospitals are now part of Asia One Healthcare, which is majority-owned by Hong Leong Group and the global alternative asset management firm, TPG. Since its inception, Columbia Asia has dedicated and provided top-notch healthcare services across Southeast Asia for more than two decades. With 14 advanced medical facilities in Malaysia strategically located in densely populated areas, it aims to provide the best care possible closer to home with its tagline "Right Here For You".

Columbia Asia Group of hospitals, established in Malaysia in 1996, is an international healthcare company operating medical facilities in Malaysia, Indonesia, and Vietnam. Columbia Asia hospitals are now part of Asia One Healthcare, which is majority-owned by Hong Leong Group and the global alternative asset management firm, TPG. Since its inception, Columbia Asia has dedicated and provided top-notch healthcare services across Southeast Asia for more than two decades. With 14 advanced medical facilities in Malaysia strategically located in densely populated areas, it aims to provide the best care possible closer to home with its tagline "Right Here For You".