The Medical Coder is responsible for translating medical diagnoses, procedures, and services into standardized codes for billing and documentation purposes. This role ensures accuracy and compliance with coding guidelines and regulations.

Responsibilities:
Managerial

• Support departmental objectives and contribute to operational efficiency.
• Participate in departmental meetings, committees, and hospital initiatives as required.
• Assist in the orientation and training of new employees.

Technical

• Review and analyze patient medical records to identify relevant diagnoses, procedures, and treatments.
• Assign accurate ICD, CPT, HCPCS, and other applicable medical codes based on clinical documentation.
• Ensure compliance with coding guidelines, regulatory standards, payer requirements, and organizational policies.
• Collaborate with physicians and healthcare professionals to clarify documentation and coding-related queries.
• Assist in resolving coding discrepancies, claim denials, and reimbursement issues in coordination with relevant departments.
• Maintain confidentiality, accuracy, and integrity of patient records and coding information.
• Stay updated with changes in coding standards, healthcare regulations, and industry best practices.
• Apply technical knowledge of medical sciences, including anatomy, physiology, and disease processes, to coding activities.

Quality & Safety

• Promote quality improvement initiatives and ensure adherence to established quality standards.
• Comply with all quality assurance, safety, and infection prevention and control policies and procedures.
• Support clinical audit activities and implement corrective actions as required.
• Maintain effective communication with patients, families, physicians, and other healthcare professionals when necessary.
• Ensure environmental safety and adherence to infection control measures to minimize healthcare-associated infections.

Continuous Education & Professional Development

• Participate in departmental education programs, training sessions, case reviews, and clinical presentations.
• Attend lectures, seminars, workshops, and online learning activities to maintain professional competency.
• Complete all mandatory training, certifications, licensure requirements, and regulatory compliance activities within designated timelines.
• Contribute to staff development initiatives through teaching, mentoring, and knowledge sharing.

Occupational Safety & Health (OSH)

• Comply with all Occupational Safety and Health (OSH) policies, standards, and procedures.
• Report hazards, incidents, near misses, and unsafe conditions in a timely manner.
• Participate in risk assessments, audits, inspections, mock drills, and safety awareness programs.
• Use appropriate personal protective equipment (PPE) and follow safe working practices.
• Be familiar with emergency response and evacuation procedures.
• Support waste management, recycling, and environmental sustainability initiatives.
• Ensure personal actions do not endanger the health and safety of patients, colleagues, or visitors.

Prevention & Control of Infection (PCI)

• Adhere to all Infection Prevention and Control (PCI) policies, procedures, and standards.
• Maintain the highest standards of hand hygiene, including compliance with the “5 Moments of Hand Hygiene.”
• Follow Bare Below the Elbows (BBE) requirements and environmental cleaning protocols.
• Contribute to reducing the risk of infection for patients, staff, and visitors through consistent compliance with PCI practices.

Qualifications:

• Professional certification in Medical Coding, such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or an equivalent recognized certification.
• In-depth knowledge of ICD-10-CM, CPT, and HCPCS coding systems and guidelines.
• Strong understanding of medical terminology, anatomy, physiology, and disease processes.
• Proficiency in Hospital Information Systems (HIS), Electronic Medical Records (EMR), and coding software applications.
• Excellent attention to detail with strong analytical and problem-solving abilities.
• Ability to accurately interpret clinical documentation and apply appropriate coding standards.
• Effective verbal and written communication skills to collaborate with physicians, clinical staff, insurance providers, and administrative teams.
• Strong organizational and time-management skills with the ability to manage multiple tasks and meet deadlines.
• Ability to work independently and maintain a high level of accuracy in a fast-paced healthcare environment.
• Commitment to maintaining confidentiality and adhering to professional and ethical standards.