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Job Details

SIDRA4981 - Clinical Coder

Department: Medical Services Div
Division: Medical Informatics Dept
Contract Type: Full Time
Closing Date: 11-Dec-2019
Organizational Profile:

Sidra Medicine is a state of the art academic medical center that will function to the level of the highest international standards. Its clinical focus is on the specialty care of women and children.

Sidra’s Vision is: “Sidra Medicine will be a beacon of learning, discovery and exceptional care, ranked among the top medical centers in the world”.

Achieving this vision will encompass three essential activities:

World Class: Patient and Family Centered Care Health Education Biomedical Discovery

Department/Branch profile: Sidra’s Health Information Management Division ensures information management standards are consistently applied across systems to maintain the level of data integrity, quality, and privacy necessary for clinical, demographic, financial, evidentiary and administrative data to facilitate real-time healthcare delivery
Job Summary: A Clinical Coder is a professional medical practitioner responsible for medical coding.  The post holder demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10-AM, ACHI, and/or CPT and other appropriate classification systems. He/she demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated encounters/cases. Assigns codes, codes all diagnostic and operative information from the medical record using ICD-10-AM, CPT and HCPCS coding classification systems and independently quality checks own work. The incumbent selects the DRG for each inpatient case, optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions. The Clinical Coder is responsible 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 to enable accurate and optimal allocation of Diagnosis Related Group (DRG) or associated Case mix classifications for all care episodes. He/she is also responsible for working closely with quality, finance, revenue cycle departments, registration, scheduling, case management, coding coordinators, coding reconciliation specialists and compliance to resolve coding/billing issues. He/she investigates and resolves problems, complaints and incidents occurring within the coding section and assists the Manager – Coding with resolution of such issues.
Key Role Accountabilities:
  • Performs and facilitates concurrent inpatient/outpatient coding in order to establish a working DRG.

  • Ensures high quality documentation that is thorough, accurate and complete to ensure accurate reimbursement capture.

  • Reviews health records, identifies key clinical data elements within the record, and translate this data from verbal description of disease, injuries and procedures into numerical designations, applying ICD coding systems.

  • Audits for documentation appropriateness and queries clinical staff with CDI to fill in any gaps, clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time. Reviews for document deficiencies and communicates policies and guidelines to physicians to improve documentation; including direct interaction with the relevant clinicians

  • Ensures accurate coding and sequencing as specified by established coding principles and guidelines, following the clinical coding system to derive the appropriate DRG or similar care classification system required.

  • Ensures implementation of coding productivity and quality guidelines, including audits, to ensure timeliness and accuracy of final diagnoses

  • Assists the Manager – Coding with the review process including record review, report generation and other duties as needed

  • Allocates the appropriate specific codes from the indexing system and assigns the codes for completing coding summary of the medical records

  • Investigates and resolves problems, complaints and incidents occurring within the coding section, and reports these occurrences to the Manager – Coding

  • Ensures consistency in information data flow and documentation requirements for effective medical coding and grouping; including development of advice sheets for clinicians to highlight key issues.

  • Keeps abreast of clinical coding standards, reporting, and information policies according to Australian Standards and further develop standards according to Qatar healthcare requirements.

  • Assigns appropriate codes for each diagnosis and procedure based on ICD 10 AM conventions and standards

  • Able to use the 3M encoder software and generate reports for case mix analysis.

  • Assists in data gathering for research, studies, and statistics.

  • Accounts for daily discharges and performs audit as necessary.

  • Updates clinical coding data quality group with findings and recommendations from clinical coding audits.

  • Provides a source of expertise and guidance on diagnosis and procedure coding to all disciplines within Sidra.

  • Ensures continuous studies on coding practices and coding schemes to enhance the accuracy and timely completion of coding data

  • Ensures prioritization of coding tasks as assigned by manager

  • Monitors daily coding compliance record reviews

  • Queries clinicians and works with case managers and discharge planners to ensure accurate codes are assigned based on documentation”

  • Creates reports on unbilled records due to documentation, charge and/or registration errors

  • Reports the number of DRG / coding changes below Sidra’s specified threshold to the Manager - Coding

  • Ensures codes are supported by provider documentation and initiates appropriate queries based upon other clinical documentation for accurate and reliable data collection and reimbursement

  • Monitors coding systems to ensure optimal performance and recommends upgrades or changes to current system

  • Ensures coding compliance and acts as technical resource, resolves issues, educates and works closely with Clinical Documentation Improvement Specialist.

  • Implements changes in coding rules regarding correct coding initiatives and coding clinics as received from the Manager – Coding

  • Stays abreast of changes in laws, regulations and policies that impact clinical documentation, reimbursement and coding to assure compliance

  • Monitors the coding/ abstracting systems and ensures that appropriate computer systems are updated with the annual code changes and any other associates changes or updates

  • Implements and monitors policies and procedures, guidelines and compliance plan for coding; ensures coding processes are compliant and efficient

  • Works cooperatively with revenue cycle departments, registration, scheduling, case management, coding coordinators, coders, coding reconciliation specialists and compliance officer to resolve coding/ billing issues

  • Achieves and maintains coding productivity standards for each specific account.

  • Assists in other related projects as necessary.

  • Maintains coding credential requirements.

  • Adheres to Sidra’s standards as they appear in the Code of Conduct and Conflict of Interest policies

  • Adheres to and promotes Sidra’s Values

     

    In view of the evolving needs and opportunities within Sidra, this position may be required to perform other duties as assigned and reporting relationships may vary.

Qualifications, Experience and Skills:

 

 

ESSENTIAL

PREFERRED

Education

Bachelor’s Degree in a relevant field

Formal HIM Qualification

Experience

5+ years’ experience in coding clinical information systems inclusive of 2+ years senior lead experience in HIM/ Coding

 

Certification and Licensure

HIMAA qualifications of advanced level and proficiency in ICD-10 AM and ACHI

 

Professional Membership

 

 

Job Specific Skills and Abilities

  • Proficiency ICD-10 AM and ACHI coding for inpatient, outpatient, ambulatory surgery, observations, emergency department visits, and ancillary services

     

  • Demonstrated Casemix systems knowledge; especially DRG systems.

     

  • Experience in working with billing systems

     

  • Proficiency with Microsoft Office suite

     

  • Fluency in written and spoken English
  • Cerner Millennium

     

  • 3M Coding Encoder experience
Sidra’s Organizational Values:
  • Trust: Being competent; acting consistently, reliably and predictably; acting with honesty and integrity; respecting patient, employee and commercial confidentiality; delivering on commitments
  • Care: Acting with empathy, kindness and compassion; being humble; listening and responding; acting with cultural sensitivity; Caring for patients and staff
  • Teamwork: Sharing information and knowledge and learning from demonstrated expertise; being respectful, and thereby earning respect of others; acting with professionalism; leading and following; collaborating and being accessible
  • Transparency: Frequent and honest communication; open access to information for decision making; willingly acknowledge shortcomings; speaking up about concerns; publishing performance indicators
  • Innovation: Freedom to innovate; welcoming ideas and encouraging creativity; supporting talent; creating confidence; celebrating successes
  • Efficiency: Providing measurable value; using data to drive decision making; having and achieving clear goals; building processes that work; continuously improving outcomes in patient and family care
Privacy and Application Policy

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