Medical Coder

A medical coder is a crucial role in the healthcare revenue cycle by translating medical diagnoses, procedures, services, and equipment into standardised codes for billing, insurance claims, and record-keeping purposes. They ensure the accuracy of the coding process, compliance with regulations, and timely processing of claims

1. Coding and abstracting

• Reviewing clinical documentation: Analyze patient records, physician notes, lab results, and other reports to identify services rendered and diagnoses.
• Assigning appropriate codes: Utilize coding systems like ICD-10 (for diagnoses) and CPT/HCPCS (for procedures) to assign accurate codes that reflect the medical situation.
• Ensuring coding compliance: Adhere to coding guidelines and policies set by government regulations and insurance payers.

2. Maintaining coding quality and accuracy

• Performing chart audits: Conduct regular audits and coding reviews to ensure the accuracy and precision of documentation.
• Identifying and resolving discrepancies: Analyze medical records for missing or ambiguous information and communicate with healthcare providers to clarify documentation when needed.
• Staying updated with coding guidelines: Keep abreast of changes and updates in coding regulations, policies, and industry trends to maintain knowledge of best practices.
• Participating in quality improvement initiatives: Assist in maintaining coding quality metrics and actively engage in efforts to enhance accuracy and efficiency.

3. Collaboration and communication

• Collaborating with cross-functional teams: Work closely with healthcare providers, billing specialists, and compliance officers to ensure smooth coding and billing processes.
• Communicating with insurance companies: Address coding errors and disputes with insurance companies to ensure claims are processed correctly.
• Training and education: Provide training and support to clinical staff on documentation improvement initiatives, potentially including new coding guidelines.

5 days working , 9 hour shift, Rotational off.