Clinical Coder-Coding

Role Overview

Clinical Coder-Coding at Sheikh Shakhbout Medical City (SSMC). The position reviews, analyzes, and codes hospital medical record documentation to select and sequence appropriate ICD-10-CM diagnosis and CPT procedure codes, utilizing 3M Coding Reimbursement software.

Role Purpose

To assign accurate diagnosis and procedure codes for complex inpatient, outpatient, emergency department, and observation encounters while ensuring compliance with official coding guidelines, regulatory requirements, and reimbursement standards. The role supports revenue cycle management and clinical documentation integrity through precise coding and query resolution.

Key Responsibilities

Coding & Code Assignment

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters, outpatient, emergency department, or observation short stay.
• Assign Present on Admission values for inpatient diagnoses.
• Understand appropriate linkage of diagnosis to procedure when applicable.
• Maintain accuracy and completeness of code assignment as supported by documentation.
• Consult reference materials and encoder software to facilitate code assignment.
• Utilize retrospective edit tools to address possible coding and documentation issues related to submitted diagnosis and procedure information.

Documentation Review & Analysis

• Prepare and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions, surgical procedures, and evaluation and management levels.
• Review documentation to verify and correct patient disposition upon discharge when necessary.
• Validate charges by comparing charges with health record documentation as necessary.
• Ensure accurate assignment of physician name against each service and accurate time and date.

Query & Communication

• Ensure accurate coding by clarifying diagnosis and procedural information through a query process.
• Consult with Clinical Documentation Improvement, physicians, or other healthcare providers when additional information is needed for coding or to clarify conflicting or ambiguous information.
• Interact with physicians and other areas when additional coding information is needed to prevent medical necessity denials.
• Engage with physicians in the coding query process and provide training as necessary.

Compliance & Guidelines

• Adhere to official coding guidelines when coding with accuracy and completeness.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Ensure that codes are assigned correctly and sequenced appropriately as per government and insurance regulation.

Production & Workload Management

• Maintain the assigned target of production and accuracy of coding.
• Prioritize work to ensure medical record coding meets regulatory timeframe requirements.
• Manage stressful situations and handle multiple tasks at one time.
• Code encounters of multiple specialties.

Revenue Cycle & Reporting

• Collaborate with Revenue Cycle Management teams in resolving billing and utilization issues affecting reimbursement.
• Prepare statistics as requested by management.

Team & Training

• Mentor and train other coding levels.
• Encourage a positive environment for other staff members.
• Collaborate with other members of the team to carry out work smoothly.
• Assist in any other relevant task that may be assigned.

Qualifications & Experience

• Bachelor Degree in Health Information Management or relevant field, OR Diploma with 3 years of additional experience in Healthcare.
• 2–4 years of relevant progressive experience in a similar role.
• Desired: Master degree or equivalent in Health Information Management or relevant field.
• Desired: Experience in a large healthcare facility.

Skills & Competencies

• Proficiency with 3M Coding Reimbursement software.
• Encoder software and online coding reference tools.
• ICD-10-CM diagnosis and CPT procedure coding.
• Clinical documentation analysis.
• Query and clarification processes.
• Knowledge of government and insurance regulations.
• Revenue cycle principles and billing processes.
• Multitasking and stress management.
• Team collaboration and mentoring.