Clinical Coder-Coding

JOB DESCRIPTION

The Clinical Coder reviews, analyzes, and codes documentation for hospital medical records to select and sequence the appropriate ICD-10-CM diagnosis, CPT procedure codes as applicable. This position is responsible for the accurate assignment; abstracting to determine accuracy and completeness of the record, utilizing the 3M Coding Reimbursement to compile data and related work assigned. Coding staff in this position are able to code encounters of multiple specialties, as well as mentor and train other coding levels. This position (utilizing encoder software and online tools and references in the assignment of codes). Consults reference materials to facilitate code assignment. Validates charges by comparing charges with health record documentation as necessary. Understands appropriate link of diagnosis to procedure when applicable. Utilizes retrospective edit tool to address possible coding and/or documentation issues related to submitted diagnosis and procedure information obtained from the health record. Consults with CDI, physicians, or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous information. Collaborates with Revenue Cycle Management teams in resolving billing and utilization issues affecting reimbursement.

RESPONSIBILITIES

• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters, outpatient (OP)/emergency department (ED) or observation short stay.
• Prepares and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures and E&Ms.
• Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.
• Ensures accurate coding by clarifying diagnosis and procedural information through a query process.
• Assigns Present on Admission (POA) value for inpatient diagnoses.
• Assigns an accurate physician name against each service and accurate time and date.
• Interacts with physicians and other areas when additional coding information is needed; example to prevent medical necessity denials.
• Reviews documentation to verify and when necessary, correct the patient disposition upon discharge.
• Maintains the assigned target of production and accuracy of Coding.
• Prioritizes work to ensure timeframe of medical record coding meets regulatory requirements.
• Engages with physicians in Coding Query process and provides training as necessary.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Prepares statistics as requested by the management.
• Assists in any other relevant task that may be assigned
• Manages stressful situations and handles multiple tasks at one time
• Encourages a positive environment for other staff members.
• Collaborates with other members of the team to carry out work smoothly
  
  

Accountabilities

• Ensures that codes are assigned correctly and sequenced appropriately as per government and insurance regulation
• Implements strategic procedures and choosing strategies and evaluation methods that provide correct results
  
  

QUALIFICATIONS

Experience :-

Required:

• 2-4 years of relevant progressive experience in a similar role
  
  

Desired:

• Experience in a large healthcare facility
  
  

Educational Qualification: Required:

• Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare
  
  

Desired:

• Master degree or equivalent in Health Information Management or relevant field
  
  

ABOUT US

At SSMC, we firmly believe that the human touch is a fundamental part of care. We understand that health care is both an art and a science, running deeper than simply diagnosing and treating those who rely on us. Our SSMC Model of Care puts our patients at the forefront of our purpose and at the heart of everything we do, ensuring that the needs of our patients come first. Every one of our patients receives individualized attention from a multidisciplinary team of experts who collaborate closely to deliver trusted and compassionate care. From the very first point of contact with SSMC, to the moment patients are back home, we ensure speciality-specific care at every stage and in every interaction. As one of the largest tertiary hospitals in the UAE, SSMC provides access to specialist medical treatments and advanced diagnostics, with a commitment to becoming a Destination Medical Center in the UAE and wider region.

ABOUT THE TEAM

About Sheikh Shakhbout Medical City (SSMC)

SSMC is the largest tertiary hospital in the UAE and serves to elevate the provision of health care services in the nation under the mandate of the Abu Dhabi Economic Vision 2030.

Supported by the latest diagnostic and treatment modalities available, SSMC offers care in 44 specialties. A team of locally and internationally trained medical, clinical and admin professionals work seamlessly together, which promotes comprehensive interdisciplinary learning, allowing SSMC to become a leading hub for integrated patient-centric medical services in the region.

As the region’s leading tertiary facility, SSMC has 742 patient beds, 18 operating theatres, and includes a hybrid operating room, 26-bed neonatal intensive care unit, and the UAE’s largest pathology lab.