CODER, MEDICAL RECORDS

• Researches medical records to develop complete codes for all diagnoses and procedures.
• Applies anatomy, physiology, disease process, and medical terminology knowledge to interpret the record and select accurate codes.
• Interprets and translates clinical documentation from the medical record into diagnostic and procedural codes; abstracts data into a computer database.
• Responsible for thoroughly knowing and utilizing all inpatient and outpatient coding systems according to the most recent rules, regulations, and conventions.
• Contacts physicians as necessary to request complete information and/or clarification to complete code the patient records.
• Maintains an accurate and timely computerized database utilizing prescribed abstract format.
• Maintains coding skills and professional credentials with appropriate continuing education by reading and applying coding materials and policies.
• Prepares or assists with preparing statistical or other special reports relating to patients, diseases, and treatments as needed.
• Performs audits and quality checks, provides training to trainees, and participates in Health Care Providers education as required.
• Keeps close communication and feedback loop with the clinical documentation team to improve documentation.
• Acts at all times as a service representative of the department. Provides cross-coverage for other positions in the department as requested by the management.
• Follows all Hospital’s related Policies and Procedures.
• Participates in self and others' education, training and development, as applicable.

• Completion of Hospital approved Coder Training Program is required.
• Certified Introductory level Clinical Coding Certificate or higher.
• Current Registration from country of origin and Saudi Commission for Health Specialties (SCHS) is required.

King Faisal Specialist Hospital & Research Centre