Medical Coding jobs in Delhi, Delhi

Job Summary

The Medical Record Technician is responsible for maintaining accurate, complete, confidential, and easily retrievable patient medical records in accordance with hospital policies, NABH standards, legal requirements, and applicable government regulations.

Key Responsibilities1. Medical Record Management

• Receive, verify, arrange, and maintain all inpatient and outpatient medical records.
• Ensure patient files are complete before filing.
• Assign and maintain Medical Record Numbers (MRN) as per hospital policy.
• File records systematically for easy retrieval.
• Archive and preserve medical records according to the retention policy.

2. Documentation Review

• Check patient files for completeness before closure.
• Verify that all required documents are present, including:
• Admission form
• Consent forms
• Doctor's notes
• Nursing records
• Investigation reports
• OT notes
• Discharge summary
• Billing clearance
• Coordinate with departments to obtain missing documents.

3. Coding & Indexing

• Perform disease and procedure coding (ICD-10/ICD-11 as applicable).
• Maintain diagnosis and procedure indexes.
• Assist in generating disease statistics and hospital reports.

4. Record Retrieval

• Retrieve patient records when requested by authorized personnel.
• Maintain proper issue and return registers.
• Ensure records are returned promptly.

5. Confidentiality

• Maintain strict confidentiality of patient information.
• Release medical records only after proper authorization.
• Comply with applicable privacy laws and hospital confidentiality policies.

6. Digital Record Management

• Scan and upload patient documents into the Hospital Information System (HIS).
• Ensure electronic records are complete and accurate.
• Maintain backup and indexing of digital records.

7. Quality Assurance

• Conduct regular audits of medical records.
• Report incomplete documentation to concerned departments.
• Support NABH, insurance, CGHS, Ayushman Bharat (PM-JAY), and other regulatory audits.

8. Statistical Reporting

• Prepare daily, weekly, and monthly MRD reports.
• Maintain hospital statistics including:
• OPD/IPD census
• Admissions
• Discharges
• Deaths
• Bed occupancy
• Average Length of Stay (ALOS)

9. Record Retention & Disposal

• Preserve records as per legal retention requirements.
• Prepare records for secure destruction after the retention period with management approval.
• Maintain destruction registers.

10. Coordination

• Coordinate with:
• Doctors
• Nursing staff
• Billing Department
• Insurance/TPA Department
• Front Office
• Quality Department
• Administration

Daily Responsibilities

• Collect completed patient files.
• Verify document completeness.
• File and retrieve medical records.
• Scan and upload documents.
• Update MRD registers.
• Respond to record requests.
• Maintain confidentiality.

Skills Required

• Knowledge of medical terminology.
• Understanding of ICD coding.
• Computer proficiency (MS Office, HIS).
• Record management and filing skills.
• Attention to detail.
• Good communication skills.
• Time management.
• Ability to maintain confidentiality.

Pay: ₹15,000.00 - ₹27,284.32 per month

Work Location: In person