Clinical Coder

Summary

Clinical coders translate descriptions of medical diagnoses and procedures into codes, which record healthcare data.

Duties & Tasks

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 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 Australian Modification, commonly referred to as ICD-10-AM
  • conduct assessment of work to ensure 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
  • work with computing and finance staff
  • ensure the patient episode is allocated to the correct Diagnosis Related Group (DRG)
  • assist with medical research and casemix (patient statistics) projects.

Working Conditions

Clinical coders work closely with medical staff who are responsible for recording the information required for coding medical data within patients' medical records.

Personal Requirements

  • able to perform precise and detailed work
  • able to concentrate for long periods of time
  • excellent problem-solving skills
  • good communication and interpersonal skills
  • able to work as part of a team
  • interested in healthcare procedures
  • willing to continually update skills and knowledge.

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