Medical Coder

Basic Purpose of the role

The Clinical Coder is responsible for for reviewing and analyzing medical records in order to abstract relevant data from patient medical records and ensuring appropriate codes are assigned in accordance with the clinical coding system. The Clinical Coder shall ensure that the financial activities for patients shall run efficiently and effectively according to best international standards by following the facility’s approved  policies and procedures. 

Key responsibilities of the role

Assists in formulating and ensuring delivery of the Hospital corporate strategies and strategic plans.

Work with the Senior Clinical Coder to develop the patient’s Financial service standards and ensure they are consistently met. Acting as a role model, they will deliver high operational performance standards by developing and supporting the Finance team.

Collaborates with all levels of interdisciplinary teams, executive officers and other stakeholders in the development, implementation, and evaluation of programs and services.
Reviewing and analyzing patient medical records to ensure all applicable patient data is available for coding and abstracting by checking the diagnosis and procedure 

Ensuring accurate coding and sequencing as specified by established coding principles and guidelines, following the clinical coding system

Allocating the appropriate and specific codes from the indexing system and assigning the codes for completing a coding summary of the medical records 

Assisting with the preparation of medical records for the quality assurance and medical audit purposes by providing the coding data

Investigating and resolving problems, complaints and incidents occurring within the coding section, and reporting these occurrences to the Senior Clinical Coder  for further action

Ensuring timely completion of medical coding as per the orders

Ensuring consistency in information data flow and documentation requirements for effective medical coding and grouping

Validating that encoded information is reported with most accurate information 

Collaborating with clinical and non-clinical staff in research projects, teaching activities, evaluation of medical records etc. by utilizing the coding database

Applying knowledge of basic medical sciences and medical terminology skills

Conducting period audit on the coding process and ensure the coding is conducted as per the set standards
Coordinating with the data analysis section for coding statistics requirements, and with other sections in medical records, for other clerical-related transactions/arrangements

Other responsibilities

Evaluates factors related to safety, outcomes, effectiveness, cost and social impact when developing and implementing practice innovations.

Participates in projects, equipment, staff and policy decisions that affect staff care.

Manages the performance of self and others within the facility by setting developmental action plans/goals.

Continues personal professional development through training and continuing education.
 

Compliance guidelines

Responsible for operational implementation and for ensuring that practice is contemporary and meets international and UAE national guidelines.

The ability to demonstrate leadership, managerial ability, good interpersonal relationships, and the application of sound administrative principles.

Completes and maintains all regulatory requirements including: licensure and certification and other mandatory training within established time frames.
Demonstrate a high standard of active listening skills as well as other verbal and written communication skills.

Ensures all staff maintains confidentiality regarding staff/patient information.

Maintaining collaborative and effective relationships with other key management personnel and keeps abreast of significant economic, social and technical trends and regulatory guidelines, which may influence assigned functions/services and/or the facility.

Functions as a resource to all Staff and acts as liaison with other disciplines and departments.

Responding to verbal and written inquiries in a timely manner

Delivering solutions to simpler issues facing the employees and presenting complex issues to the Officer/Senior Officer 

Corresponding with different vendors for the purpose of account verification and details of payment

Maintain a positive work environment for staff and promote team efforts, promote and maintain effective working relationships with all levels of staff.

Adheres to the policies of Occupational Health and Safety and Infection Control Guidelines in all work practices.
Establish and maintain professional interpersonal relationships – Developing constructive and cooperative working relationships with others and maintaining them over time.

Emotionally self-aware, practice self-control, able to empathetically interact and understand the team and their needs and demonstrates effective management of relations to ensure team success and better patient care outcomes.

Acts as a professional role model and resource person.

Qualifications, Certifications and Experience

Bachelor’s degree or equivalent in Clinical Coding or HIM
Competent computer skills.
Recognised coding certification such as Certified Coding Associate (CCA), Certified Coding Specialist (CCS) etc.
2-3 years experience in an acute care hospital Medical Record Department as a Coder of inpatient records, inclusive of ICD10-CM coding or equivalent and statistical compilation. 
International accreditation experience.

The ability to influence and implement change.
Excellent interpersonal and communication skills.
Strong analytical and problem-solving skills                
Able to work independently and collaboratively with others.
Organized and able to work methodically.
Able to relate to people from different cultural backgrounds.
Fluent in both written and spoken English.
The ability to speak Arabic is highly preferred.
 

Physical requirements

Typical physical demands include: a high degree of manual dexterity to sufficiently perform computer functions on a keyboard, produce materials on a PC and operate basic office equipment, normal or corrected vision and hearing, extensive sitting and walking, mobility sufficient to visit with departments or employees throughout the facility and lift up to 13 kgs.