Clinical Coder is a skilled medical professional responsible for accurately coding medical diagnoses, procedures, and services. The role requires expert-level knowledge of clinical coding systems, including but not limited to ICD-10-CM, CPT-4, HCPCS, and LOINC. The Clinical Coder must have a strong understanding of human anatomy and physiology to interpret medical classifications and accurately assign codes for various patient encounters, including outpatient, inpatient, emergency, and daycare visits. Key responsibilities include coding all diagnostic, laboratory, radiology, operative, surgical, office procedures, evaluation and management (E/M) services, and consultation codes from medical records using standardized classification systems for all encounters type i.e Outpatient , Inpatinet , daycare ,pharmacy, emergency. The Clinical Coder independently performs quality checks on their own work, ensuring accuracy and compliance with coding guidelines. The Clinical Coder is also responsible for concurrent coding, reviewing medical records in real-time during a patient’s hospitalization for all encounters types to ensure accurate documentation, coding, and charge capture before discharge. This proactive approach improves billing accuracy, minimizes delays, and supports efficient claims processing. For inpatient cases, the Clinical Coder determines the appropriate Diagnosis-Related Group (DRG) to optimize hospital reimbursement ethically and in accordance with approved coding conventions. The role involves reviewing and analyzing medical records to extract relevant data and ensure precise code assignment, supporting accurate case mix classification and optimal financial outcomes. Additionally, the Clinical Coder plays a crucial role in charge capture, ensuring that all billable services and procedures are correctly recorded and appropriately linked to the patient’s account. By validating and reconciling charges against clinical documentation, they help prevent revenue loss and billing discrepancies. The Clinical Coder collaborates closely with departments such as Quality, Finance, Revenue Cycle, Registration, Scheduling, Case Management, and Compliance to resolve coding and billing issues. They investigate and address problems, complaints, and incidents related to coding and assist the Coding Manager in resolving such matters efficiently. ResponsibilitiesKEY ROLE ACCOUNTABILITIES Medical Coding & Documentation Performs and facilitates concurrent inpatient, emergency and outpatient coding. Assigns appropriate codes for diagnoses and procedures using ICD-10-CM,CPT 4 ,HCPCS,LOINC conventions and standards. Reviews health records, identifies key clinical data elements, and translates them into numerical designations using ICD coding systems. Ensures accurate coding and sequencing in compliance with established coding principles and guidelines. Uses 3M encoder software to generate reports for case mix analysis. Clinical Documentation Improvement (CDI) & Quality Assurance Ensures high-quality documentation that is thorough, accurate, and complete to facilitate proper reimbursement. Audits for documentation appropriateness and collaborates with Clinical Documentation Improvement (CDI) specialists to clarify missing, incomplete, or conflicting information in real time. Reviews documentation deficiencies and communicates policies and guidelines to physicians to improve documentation. Assists in coding quality audits, ensuring compliance with coding productivity and accuracy guidelines. Updates the Clinical Coding Data Quality Group with findings and recommendations from coding audits. Charge Capture & Revenue Integrity Works with case managers, discharge planners and financial counselling to ensure accurate coding and charge capture. Creates reports on unbilled records due to documentation, charge, or registration errors. Ensures codes are supported by provider documentation and initiates appropriate queries for clarification. Monitors coding compliance through daily record reviews and maintains coding productivity standards. Compliance & Regulatory Adherence Ensures coding processes adhere to international standards and Qatar healthcare regulations and coding guidelines. Monitors changes in laws, regulations, and policies affecting clinical documentation, coding, and reimbursement. Implements and monitors coding policies, procedures, and compliance plans to enhance efficiency. Ensures that annual coding updates and system upgrades are applied to maintain compliance with regulations. Collaboration & Issue Resolution Investigates and resolves coding-related problems, complaints, and incidents, escalating them to the Coding Manager as needed. Collaborates with Revenue Cycle, Registration, Financial Counselling , Scheduling, Case Management, and Compliance teams to resolve coding and billing issues. Provides expertise and guidance on diagnosis and procedure coding to all disciplines within Sidra Medicine. Develops and maintains advice sheets for clinicians, ensuring consistency in data flow and documentation requirements. Education, Training & Professional Development Provides coding education and support to physicians, clinical teams, and other relevant stakeholders. Conducts continuous studies on coding practices to enhance accuracy and timely completion of coding data. Maintains professional coding credentials and participates in ongoing training and development. System Monitoring & Performance Optimization Monitors the coding and abstracting systems for optimal performance, recommending system upgrades or changes when needed. Reports the number of DRG/coding changes below Sidra’s specified threshold to the Manager – Coding. Implements coding rule changes related to Correct Coding Initiatives (CCI) and Coding Clinics as directed by the Manager – Coding. Stays updated on evolving best practices in coding, documentation, and reimbursement. Additional Responsibilities Assists in data gathering for research, studies, and statistical reporting. Supports other related projects as necessary. Accepts additional duties as required, in response to the evolving needs and opportunities within Sidra Medicine 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 QualificationsQUALIFICATIONS, EXPERIENCE AND SKILLS – SELECTION CRITERIA ESSENTIAL PREFERRED Education Bachelor’s Degree in Medical Records or Health Information, Allied Health Sciences or related field. Experience 5+ years of experience inclusive of; Experience in coding clinical information systems, medical records/health information in American Coding Guidelines standards Experience in ICD10 CM/CPT 4 and HCPCS coding Utilization Management experience  Certification and Licensure Credentialed Coder Certificate (CPC, CCS) Registered Health Information Certificate (RHIT, RHIA) Professional Membership Job Specific Skills and Abilities Knowledge of the guidelines related to the coding systems, DRG methodology and the ability to follow the detailed guidelines related to their use, understands the importance of proper sequencing and coding according to official coding guidelines Understanding of disease process, anatomy & physiology necessary for assigning accurate numeric and alpha-numeric codes and medical terminology proficiency Proficiency in coding outpatient and inpatient Proficiency in ICD10 CM ,CPT 4 and HCPCS for inpatient, outpatient, ambulatory surgery, observations, emergency department visits, and ancillary services Demonstrates ability to achieve accuracy and consistency in the selection of principal and secondary diagnoses (including MCC & CC) and procedures. Demonstrates ability to achieve accuracy and consistency in abstracting elements defined by per facility. Demonstrates Case mix systems knowledge; especially DRG systems. Experience with coding complex cardiovascular, cardiothoracic, transplant, and neurological procedures. Strong analytical and problem solving skills Experience in working with billing systems Proficiency with Microsoft Office suite Fluency in written and spoken English Cerner Millennium 3M Coding Encoder experience