أخصائي ترميز طبي للعيادات الخارجية

Job Summary

The OP Medical Coder is responsible for accurately reviewing and coding outpatient medical records, diagnoses, procedures, and services according to established coding guidelines and payer requirements. The role ensures that medical documentation is translated into accurate ICD, CPT, HCPCS, and other applicable codes to support appropriate billing, reimbursement, reporting, and compliance.

Key Responsibilities

• Review outpatient medical records, physician notes, diagnostic reports, and other clinical documentation.
• Assign accurate diagnosis and procedure codes based on the documentation provided.
• Apply appropriate ICD-10-CM, CPT, HCPCS, and applicable modifiers.
• Ensure coding is supported by complete and appropriate clinical documentation.
• Identify missing, unclear, or conflicting documentation and coordinate with the appropriate clinical or coding team for clarification.
• Review outpatient encounters for coding accuracy, completeness, and compliance with applicable guidelines.
• Ensure correct sequencing of diagnoses and procedures.
• Identify potential coding errors, denials, and documentation issues and recommend corrective action.
• Maintain confidentiality and comply with patient privacy and information-security requirements.
• Stay current with changes to coding guidelines, payer policies, regulatory requirements, and coding updates.
• Participate in internal audits, quality reviews, and coding education activities.
• Meet established productivity and accuracy standards.
• Collaborate with physicians, clinical staff, billing teams, and other departments to resolve coding-related issues.
• Support denial management and provide coding-related information when required.

Required Qualifications

• Diploma or Bachelor's degree in Medical Coding, Health Information Management, Medical Records, Healthcare Administration, or a related field.
• Professional medical coding certification such as CPC, CCS, CCA, or an equivalent qualification is preferred.
• Knowledge of ICD-10-CM, CPT, and HCPCS coding systems.
• Understanding of outpatient coding guidelines and medical terminology.
• Familiarity with anatomy, physiology, and common medical procedures.
• Previous experience in outpatient medical coding is preferred.

Required Skills

• Strong attention to detail and accuracy.
• Good knowledge of medical terminology and clinical documentation.
• Ability to interpret physician documentation and assign appropriate codes.
• Strong analytical and problem-solving skills.
• Good written and verbal communication skills.
• Ability to work independently and meet productivity targets.
• Proficiency in electronic medical records (EMR/EHR) and coding software.
• Ability to maintain patient confidentiality and professional standards.

Key Performance Indicators

• Coding accuracy and quality.
• Productivity and turnaround time.
• Reduction in coding-related denials and errors.
• Compliance with applicable coding guidelines.
• Documentation query quality and resolution.
• Adherence to organizational policies and confidentiality requirements.

Reporting

Reports to: Coding Supervisor / HIM Manager / Revenue Cycle Manager

Department: Health Information Management / Medical Coding / Revenue Cycle Management

Employment Type: Full-time