Medical Coder-Inpatient

Overview

M42 delivers comprehensive healthcare services across the full continuum of care; from primary care to advanced specialty treatments. Leveraging cutting-edge health technologies and precision medicine, we ensure the highest standards of effectiveness, efficiency, and patient-centered outcomes. With a global presence spanning more than 480 facilities in 27 countries and a dedicated workforce of over 20,000 professionals, M42 is uniquely positioned to redefine the future of healthcare on a global scale.

Danat Al Emarat is a world-class specialty women’s and children’s hospital in the Emirate of Abu Dhabi. It offers advanced medical services across specialties including Neonatology, Pediatrics, Obstetrics & Gynecology, and Women’s Health. The hospital is one of the very few to encompass a dedicated Fetal Medicine Department along with a full-fledged Neonatal Intensive Care Unit (NICU) in the UAE.

This has established Danat Al Emarat as a regional referral center for women with high-risk pregnancies, supported by its Level III NICU providing care for the most fragile newborns. The Inpatient Medical Coder is responsible for reviewing inpatient medical records and accurately assigning diagnostic and procedural codes based on clinical documentation, coding guidelines, and regulatory requirements.

The role ensures the completeness and accuracy of coded data to support appropriate reimbursement, quality reporting, compliance, and healthcare analytics. Working closely with physicians, clinical staff, case management, and revenue cycle teams, the Inpatient Medical Coder analyzes complex patient encounters, ensures adherence to ICD-10-CM and ICD-10-PCS coding standards, and contributes to the organization's financial and operational performance while maintaining the highest standards of coding integrity and patient data confidentiality.

Responsibilities

Review inpatient medical records, physician documentation, diagnostic reports, and treatment records to assign accurate ICD-10-CM and ICD-10-PCS codes. Analyze complex inpatient encounters to ensure complete and accurate coding of diagnoses, procedures, complications, comorbidities, and severity of illness. Abstract and enter coded data into the electronic health record (EHR) and coding systems in accordance with established guidelines and timelines.

Ensure compliance with official coding guidelines, regulatory requirements, organizational policies, and payer-specific standards. Review clinical documentation for completeness, accuracy, and specificity to support appropriate code assignment and reimbursement. Query physicians and other healthcare providers when clarification or additional documentation is required.

Assign and validate Diagnosis-Related Groups (DRGs) to support accurate reimbursement and case classification. Collaborate with Clinical Documentation Improvement (CDI) specialists, physicians, case managers, and revenue cycle teams to optimize coding quality and documentation integrity. Conduct coding audits and participate in quality assurance activities to maintain coding accuracy and compliance.

Identify coding trends, documentation deficiencies, and opportunities for process improvement. Support internal and external audits by providing coding rationale and required documentation. Monitor coding-related denials and work with relevant departments to resolve coding and documentation issues. Ensure appropriate capture of patient acuity, complications, comorbidities, and procedures to accurately reflect the patient's clinical condition.

Maintain productivity, quality, and turnaround time standards established by the organization. Stay current with updates to ICD-10-CM, ICD-10-PCS, DRG methodologies, coding regulations, and reimbursement guidelines.

Qualifications

Bachelor's degree in Health Information Management, Medical Records, Healthcare Administration, Nursing, Pharmacy, or a related healthcare field. Professional coding certification such as CPC (Certified Professional Coder), ICD-10-CM, CPT, and HCPCS Review inpatient medical records, physician documentation, diagnostic reports, and treatment records to assign accurate ICD-10-CM and ICD-10-PCS codes.

Analyze complex inpatient encounters to ensure complete and accurate coding of diagnoses, procedures, complications, comorbidities, and severity of illness. Abstract and enter coded data into the electronic health record (EHR) and coding systems in accordance with established guidelines and timelines. Ensure compliance with official coding guidelines, regulatory requirements, organizational policies, and payer-specific standards.

Review clinical documentation for completeness, accuracy, and specificity to support appropriate code assignment and reimbursement. Query physicians and other healthcare providers when clarification or additional documentation is required. Assign and validate Diagnosis-Related Groups (DRGs) to support accurate reimbursement and case classification.

Collaborate with Clinical Documentation Improvement (CDI) specialists, physicians, case managers, and revenue cycle teams to optimize coding quality and documentation integrity. Conduct coding audits and participate in quality assurance activities to maintain coding accuracy and compliance. Identify coding trends, documentation deficiencies, and opportunities for process improvement.

Support internal and external audits by providing coding rationale and required documentation. Monitor coding-related denials and work with relevant departments to resolve coding and documentation issues. Ensure appropriate capture of patient acuity, complications, comorbidities, and procedures to accurately reflect the patient's clinical condition.

Maintain productivity, quality, and turnaround time standards established by the organization. Stay current with updates to ICD-10-CM, ICD-10-PCS, DRG methodologies, coding regulations, and reimbursement guidelines. Bachelor's degree in Health Information Management, Medical Records, Healthcare Administration, Nursing, Pharmacy, or a related healthcare field.

Professional coding certification such as CPC (Certified Professional Coder), ICD-10-CM, CPT, and HCPCS