Clinical Coder Job Description: Top Duties and Qualifications

A Clinical Coder, or Medical Coder records clinical information about patients and translates this information into codes based on national and international standards. Their primary duties include assessing patient’s clinical statements, assigning standard codes and resolving coding queries. 


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Clinical Coder duties and responsibilities

Clinical Coders important duties and responsibilities include: 

  • Analysing patient records and recording all the relevant information
  • Examining records and documentation for missing information
  • Assigning industry-recognised codes such as ICD-10 and OPCS-4
  • Collaborating with Physicians and other healthcare professionals to ensure information accuracy
  • Training other healthcare professionals on clinical coding practices
  • Ensuring that the healthcare facility complies with clinical coding guidelines
  • Carrying our periodic audits of patients’ medical charts
  • Ensuring that all clinical codes are current
  • Assigning and sequencing all codes for services rendered


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What does a Clinical Coder do?

Clinical Coders are responsible for transforming healthcare procedures, diagnoses, equipment and medical services into universal medical alphanumeric codes. They assign the correct code to describe the kind of service or procedure a patient will receive. Clinical Coders ensure the codes are applied correctly during the process of medical billing. Clinical Coders work in clinics, hospitals and physicians’ offices. 


Clinical Coder skills and qualifications

Clinical Coders need a combination of computer skills, organisation and thoroughness, and knowledge of medical coding principles to perform their duties effectively. A successful Clinical Coder will have various prerequisite  skills and qualifications that typically include:

  • Extensive knowledge of medical terminology
  • In-depth understanding of clinical coding standards
  • Data entry skills
  • Working knowledge of relevant software packages
  • Excellent verbal and written communication skills
  • Ability to work well in a team
  • Problem-solving skills
  • Attention to detail


Clinical Coder experience requirements

Clinical Coder positions usually need several years of experience in clinical coding, medical record-keeping or a related field. Mid-level Clinical Coder positions require candidates to have three to five years of experience, while Senior Clinical Coder positions require over five years of experience in the field plus supervisory experience. A strong background in clinical coding standards and prior experience in data entry, mathematical analysis, customer service is a plus. 


Clinical Coder education and training requirements

Clinical Coders must have GCSEs. They must also have a degree in health information technology, medical coding or a related field. Many employers prefer candidates who have a National Clinical Coding Qualification, which a nationally-recognised qualification for Clinical Coders working in the United Kingdom. 

Other training requirements include the Level 3 Clinical Coding Apprenticeship that includes a 21-day course in Clinical Coding Standards. This course teaches OPCS-4 coding standards.


Clinical Coder salary expectations

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Clinical Coder job description FAQs


What should you look out for in a Clinical Coder's CV?

When reviewing a Clinical Coder’s CV, look for their experience and measurable achievements. Make sure they are familiar with the three categories of clinical codes: International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS). Also, check if they have the National Clinical Coding Qualification and the skills required to make sure they are the right fit for the job. 


What are the different types of Clinical Coders?

There are two main types of Clinical Coders: In-patient Clinical Coders and Clinical Outpatient Coder. In-patient Clinical Coders work in a hospital’s emergency department, billing department, surgical department or laboratory. Clinical Outpatient Coders work in radiology labs, diagnostic labs or private practices. 


How do I make my Clinical Coder job description stand out?

A good Clinical Coder job description will help candidates decide whether their skills, experience, education and values match the open role at your company. Start your job description with a short overview of your company, then list out the responsibilities you expect the Clinical Coder to perform and outline the skills they will need. Also, include the education and experience requirements and a salary range to attract the right candidates.


What is the difference between a Clinical Coder and a Medical Biller?

Clinical Coder and Medical Billers are quite similar in that they both perform administrative duties within the healthcare industry and handle patients’ medical records. After Clinical Coders have assigned the relevant codes to patient data, Medical Billers input these codes into special medical billing software to ensure that insurance claims are filed accurately. 

Medical Billers go a step further than Clinical Coders to explain insurance coverage packages, co-payments and deductibles to patients. In addition, they follow up with them to ensure that claims are paid. Medical Billers also ensure that the healthcare facilities are adequately reimbursed by the insurance company. Although they receive the same general training, Clinical Coders require more in-depth knowledge of medical terminology and human anatomy.

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