Job Description

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Medical Coder

Posted On: Tuesday, December 2nd, 2025
Description

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:



Organizational Accountabilities:


Follow all relevant policies, processes, standard operating procedures, and instructions and ensure work is carried out in a controlled and consistent manner.

Promote the implementation and adherence to relevant policies, processes, and operating procedures to others. Contribute to the identification of opportunities for continuous improvement of systems, processes, and practices, taking into account leading practices, improvement of department processes, cost reduction, and productivity improvement. safety, quality, and environmental management policies, procedures, and controls to ensure safety, legislative compliance, delivery of high-quality service, and a responsible environmental attitude. Build high levels of trust and understanding with key internal and external stakeholders to promote full compliance with industry regulations and promote a broader understanding of Dallah Health's interests and practices.


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)



Requirements

Job Qualifications and Requirements:


Knowledge and Experience


2-4 years of relevant coding experience in a hospital environment


? Strong knowledge of MOH coding standards, Saudi data privacy requirements, and CBAHI/JCI accreditation frameworks.


? In-depth experience with ICD-10-AM, ICD-11, DRG grouping, and clinical documentation improvement practices.


? Familiarity with EMR systems and coding software.


Education and Certifications:


Bachelor's degree in Healthcare Administration, Quality Management or a related healthcare field.


? Professional certification in coding (e.g., CCS, CPC) is preferred.


? Valid registration with the Saudi Commission for Health Specialties (SCFHS).


Skills:


Deep technical expertise in coding standards, documentation requirements, and coding compliance.



Summary

Career Level

Associate
Languages