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Clinical Coder
Alternative Titles:
Medical Record Coder
Clinical coders translate descriptions of medical diagnoses
and procedures into codes, which record health care data.
Clinical coders may perform the following tasks:
- read and analyse medical records to help identify all
diagnoses, operations and procedures relevant to the current
period of patient care
- clarify inconsistent, doubtful or non-specific
information in a medical record by consulting with the
responsible medical practitioner
- allocate codes to patients' current period of care,
using knowledge of the information contained within the
International Classification of Diseases, 10th Revision,
commonly referred to as ICD-10-AM
- conduct assessment of work to make sure that there is
continuous improvement in ICD-10-AM coding and collection of
quality health data
- assess the medical record content and highlight
shortcomings to management
- maintain ICD-10-AM coding books to make sure they are
updated to the current version being used
- assist with the education of clinical staff with regard
to ICD-10-AM
- liaise with computing and finance staff
- assist with medical research and casemix projects.
Clinical coders work closely with medical staff who are
responsible for recording the information required for coding
medical data within the patient's medical record.
Required Skills - Clinical Coder
- able to work with a high degree of precision, paying
attention to detail in order to achieve the high levels of
accuracy required
- good communication and interpersonal skills
- able to work as part of a team
- interested in health care procedures
- willing to continually update skills and knowledge
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