KEY RESPONSIBILITIES & ACCOUNTABILITIES

ICD-10 / ICD-11 Coding & Data Entry

1.1. Assign correct ICD-10 / ICD-11 diagnosis codes for all inpatients upon discharge and foreign outpatients.

1.2. Ensure accurate data entry of diagnoses into the Hospital Information System (HIS).

Procedure & Service Coding

2.1 Assign correct procedure codes ICD-9-CM codes.

2.2 Ensure all procedures and services performed are accurately coded and entered into the Hospital Information System (HIS) in compliance with Ministry of Health (MOH) requirements.

Departmental Training Support and Coordination

3.1 Coordinate and oversee departmental training activities in collaboration with the Head of Department (HOD), ensuring timely implementation of scheduled training programmes, compliance with the Hospital’s annual training requirement of attending eight (8) talks per staff, and proper maintenance of training documentation, including attendance records and training materials.

Compliance with Regulations

4.1 Ensure strict adherence to coding guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.

4.2 Assist the Head of Department (HOD) in updating cancer notification data in the Sistem Maklumat Rawatan Perubatan (SMRP), including Pap smear results from pathology services, ensuring weekly updates, monthly Excel consolidation, and accurate data submission in accordance with registry requirements upon verification by the Head of Department (HOD).

Licensing, Compliance Reports & Statutory Submissions for Infectious Disease, Cancer, and Death Case Notifications (In the HOD’s Absence)

5.1 Assist the Head of Department (HOD) in the collection and reporting of statistical data, including mandatory reports required by the Ministry of Health (MOH), and to ensure their timely submission in accordance with established deadlines under the Head of Department (HOD)’s instructions.

5.2 Assist the Head of Department (HOD) in the registration, reporting, and notification of cancer cases to the National Cancer Registry, and to represent the department in meetings and trainings conducted by the Ministry of Health or other government agencies in the Head of Department (HOD)’s absence.

5.3 Manage and submit licensing, compliance, and statutory reports to the relevant authorities, and to ensure the accurate and timely registration of all notifications in the e-Notification portal in the Head of Department (HOD)’s absence.

Death Registration and Mortality Reporting

6.1 Assist the Head of Department (HOD) in following up on Rest in Peace (RIP) cases, including mortality reports and Rest in Peace (RIP) discharge documents, ensuring report completeness and submission of the preliminary death review form to the Medical Director within 24 hours of death occurrence for further review at the Mortality and Morbidity Review Committee Meeting.

Committee Meetings Coordination (In the HOD’s Absence)

7.1 To involve in and coordinate the Monthly Mortality Review Meeting.

7.2 To manage the application and tracking of CPD points with the Malaysian Medical Association.

EMR Workflow Management & Support

8.1 Assist the Head of Department (HOD) in merging medical records upon request or identification of duplicate MRNs, ensuring proper verification of patient information and record accuracy prior to merging.

8.2 Assist Medical Records Clerk II in deleting medical records upon request in his/her absence, as instructed by the Head of Department (HOD).

8.3 Assist the Head of Department (HOD) in monitoring the completeness of discharge summaries within 72 working hours of patient discharge, issuing follow-up slips and email reminders to medical practitioners on non-compliance, and escalating unresolved cases to the Head of Department (HOD).

8.4 Assist the Head of Department (HOD) in providing Electronic Medical Records (EMR) user training, troubleshooting minor system issues, and ensuring compliance with digital record management policies as assigned.

8.5 Act as the second-in-charge in the absence of the Head of Department (HOD), overseeing the management of Electronic Medical Records (EMR) System and serving as the cross-departmental liaison for inquiries related to the Electronic Medical Records (EMR) System, as well as handling inquiries related to Ministry of Health (MOH) governance requirements, including e-reporting and JPN processes.

Confidentiality & Data Security

9.1 Maintain strict confidentiality of medical records and ensures controlled access to patient files as per Hospital’s policies.

9.2 Assist the Head of Department (HOD) in coordinating annual verification of authorized personnel specimen signatures from clinical departments and clinics.

Document Scanning & Record Management

10.1 Assist Medical Records Clerks with scanning and uploading of medical records during high workload periods or staff shortages, ensuring 100% accurate upload rate within 24 working hours of receipt as assigned by the Head of Department (HOD).

Medical Records Quality Control & KPIs

11.1 Assist in the compilation of monthly medical records statistics, Key Performance Indicators (KPIs), and regulatory notifications when required.

11.2 Assist the Head of Department (HOD) in monthly Medical Records Documentation Audit programme and the annual Medical Records Department Survey programme.

11.3 Assist the Head of Department (HOD) in conducting regular interdepartmental audits to ensure accuracy and compliance in the scanning, uploading, and physical archiving of medical records.

11.4 Assist and participate in internal audit programmes and external surveys, ensuring compliance with the Hospital’s policies, regulatory requirements, and quality standards.

Medical Records Disposal

12.1 Extract the list of disposed medical records that have exceeded the retention period from the Electronic Medical Records (EMR) System and submit it to the Medical Records Clerk II for the biannual disposal process of physical medical records, after completion of disposed records preparation by the Medical Records Clerks.

MRD Meetings Coordination

13.1 Serve as Secretary of Medical Records Department meetings by coordinating monthly meetings, preparing agendas, and documenting meeting minutes.

Other Duties

14.1 Undertake other related duties within the scope of this role as directed by the Head of Department (HOD) / Quality Assurance Manager.

14.2 To assume and perform the duties of the Head of Department (HOD) during his /her absence as directed by the Quality Assurance Manager.

REQUIREMENTS

Diploma/Certificate in related field
ICD Certification with coding experiences.
Nursing background would be an added advantage. He or she shall be equipped with computer literacy

Application Question(s):

Notice Period
Expected Salary

Work Location: In person

3份Hospital Fatimah 工作机会 - 最新工作招聘 - November 2026

管理提醒

Cook

Medical Records Clerk (12 Months Contract)

Medical Records Officer