Clinical Coder -General Radiology
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Key skills for this role
About the Role
Sheikh Shakhbout Medical City seeks a Clinical Coder to review, analyze, and code medical records using ICD-10-CM and CPT. The role requires accurate code assignment, abstracting, and collaboration with revenue cycle teams.
Key Skills for This Role
Responsibilities
- Assign codes for diagnoses, treatments, and procedures according to appropriate classification system for complex inpatient, outpatient, ED, or observation short stay encounters
- Review provider documentation to determine principal diagnosis, comorbidities, complications, secondary conditions, surgical procedures, and E&Ms
- Adhere to official coding guidelines and ensure accuracy and completeness
- Assign Present on Admission (POA) value for inpatient diagnoses
- Interact with physicians and other areas when additional coding information is needed
- Maintain assigned target of production and accuracy of coding
Requirements
- 2 4 years of relevant progressive experience in a similar role
- Bachelor Degree in Health Information Management or relevant field, or Diploma with 3 years additional experience in Healthcare
- Knowledge of ICD 10 CM and CPT coding
- Ability to use encoder software and online tools
Full Job Posting
Job Description
- The Clinical Coder reviews, analyzes, and codes documentation for hospital medical records to select and sequence appropriate ICD 10 CM diagnosis, CPT procedure codes.
Responsibilities
- Assigns codes for diagnoses, treatments, and procedures according to appropriate classification system for complex inpatient encounters, outpatient/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.
- 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 AHIMA.
Qualifications
- Required: 2 4 years of relevant progressive experience in a similar role
- Desired: Experience in a large healthcare facility
- Required: Bachelor Degree in Health Information Management or relevant field, or Diploma with 3 years additional experience in Healthcare
- Desired: Master degree or equivalent in Health Information Management or relevant field
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