Medical Coder

Dallah Health

Responsible for reviewing clinical documentation and assigning accurate diagnosis and procedure codes for inpatient, outpatient, or day surgery encounters. The role ensures that coding is complete, accurate, and compliant with MOH coding standards, Saudi billing and reimbursement guidelines, and CBAHI/JCI accreditation requirements. The Coding Specialist helps maintain high-quality coded data to support clinical reporting, statistical analysis, and the revenue cycle.

Key Activities:

Review patient medical records, including discharge summaries, operative reports, and clinical documentation.

Assign accurate diagnosis and procedure codes using MOH-approved coding systems (e.g., ICD-10-AM, ICD-11).

Ensure proper sequencing of codes in line with official coding guidelines and reimbursement rules.

Perform routine checks to verify that assigned codes are accurate, consistent, and complete.

Flag incomplete or unclear documentation and seek clarification through established query processes.

Participate in internal coding audits and implement feedback from audit findings.

Work with physicians, nurses, and Clinical Documentation Improvement (CDI) staff to resolve ambiguities that impact coding.

Ensure all required data elements are present for correct coding and billing.

Submit coded data within established timelines to support prompt billing and claims processing.

Assist in addressing coding-related claim denials or rejections under the guidance of the Senior Coding Specialist or Coding Manager.

Maintain strict confidentiality when handling patient information in line with MOH data privacy regulations and hospital policies.

Report any suspected compliance or privacy issues to the Coding Manager.

Keep up to date with changes in coding rules, guidelines, and reimbursement policies.

Attend coding workshops, in-service training, or certification updates as required.

Key Internal Stakeholders:

Coding Manager / Coding Assistant Manager

Coding Team, Coding Auditors, and CDI Specialists

Physicians, Nurses, and Allied Health Professionals

Revenue Cycle Management and Billing Teams

Health Information Management (HIM) Records Analysts

IT & Health Informatics Departments (for EMR and coding systems)

Key External Stakeholders:

Ministry of Health (for coding audits, statistical reporting, and regulatory compliance)

CBAHI/JCI Accreditation Surveyors

External Auditors (for coding quality reviews and case mix validation)

Approved Vendors (for coding tools, software, or audit services)