Clinical Coder
Job Description
The SEHA Hospital Coder reviews patient medical records and electronic systems to accurately assign diagnosis and procedure codes for outpatient cases using approved coding tools and references. The role includes checking documentation against charges, linking diagnoses to procedures, applying modifiers when required, and resolving coding or documentation gaps through available review systems.
Key Responsibilities
- Assign ICD-10-CM and CPT codes for outpatient and emergency department records while ensuring charges are accurately captured.
- Follow official coding rules and UAE regulatory guidelines when selecting codes based on clinical documentation.
- Use approved encoder systems and reference tools correctly during the coding process.
- Refer to recognized coding resources such as ICD coding guidelines, AHA Coding Clinic, AMA CPT Assistant, and AHIMA ethical standards.
- Contact physicians or relevant departments when clarification is needed to ensure correct coding.
- Maintain confidentiality of all patient and organizational information in line with SEHA policies.
- Complete all required licensing, certification, and mandatory training within the specified timeframes.
- Follow hospital policies, safety rules, infection control practices, and emergency procedures at all times.
- Support a respectful and professional work environment within the department and across SEHA.
- Promote a patient-focused approach in all interactions with internal and external stakeholders.
- Take responsibility for ongoing learning and skill development related to the role.
- Dress appropriately according to workplace and safety standards.
- Support mentoring, training, and development of UAE national staff as required.
- Build strong working relationships to support coordinated patient care.
- Perform other related duties as assigned by management.
Skill & Experience
- Bachelor’s degree in Health Information Management (preferred).
- Must hold at least one of the following certifications:
- Coding Specialist (CCS)
- Certified Coding Specialist – Physician-based (CCS-P)
- Certified Professional Coder (CPC)
- Certified Professional Coder – Hospital (CPC-H)
- Certified Professional Coder – Payer (CPC-P)
- Extensive knowledge of healthcare revenue cycle systems.
- Ability to review physician/provider documentation in routine outpatient (RO) health records (electronic, paper, or hybrid) to determine principal and secondary diagnoses and procedures.
- Skilled in using encoder software and applicable online coding tools to assign ICD diagnosis and procedure codes accurately.
