Job summary
An exciting opportunity has arisen to join the busy Clinical Coding Department as a Trainee Clinical Coder. This is an opportunity to train in all aspects of Clinical Coding.
The successful candidate will embrace the challenge of working in a highly demanding environment where excellent accuracy and attention to detail skills are paramount.
Coders are responsible for the timely and accurate coding of all inpatient episodes of care throughout UHP and also peripheral sites. This is a very demanding but rewarding role. Applicants should possess a good knowledge of anatomy, physiology and medical terminology
Applicants should be well organised and be able to work as a part of a team or on their own, with good time management and communication skills.
The Clinical Coding team consist of 25 coders and 3 admin support staff which includes 1 Manager, 1 Deputy Manager, 1 Auditor and Trainer, 1 support Trainer and 1 support Auditor, there are also 3 Pod Leaders.
Working as a coder requires working in a quiet working environment and requires a high degree of focus and concentration which means sitting at a desk for long periods of time.
There are excellent career opportunities to progress from Trainee B3 coders to ACC qualified B5 coders.
Preference will be given to internal Trust staff, as well as 'Priority' and 'At Risk' status including NHS at Risk staff throughout Devon who is able to display recent relevant experience as dictated by the Person Specification.
Main duties of the job
Job Purpose:
The post-holder will be a member of the Clinical Coding Team, which provides the Clinical Coding function for the Trust.
The purpose of this job is to code the diagnoses and procedures for both inpatient and day case episodes, to agreed standards of accuracy, timeliness and completeness.
All coding of inpatient/day case attendances are derived from two publications:
- The International Classification of Diseases (ICD10)
- b) The classification of Surgical Operations and Procedures (OPCS4)
The objectives of these classifications are to facilitate clinical care, to allow statistical analysis, to facilitate the transmission of data and to help fund resources. At UHP the Coding Department applies clinical coding to approximately 157,000 inpatient and day case episodes per year.
Key Dimensions:
The post-holder will be required to train in both the administration and coding role within the Coding Department. Coding needs to be completed for all inpatient spells within five working days therefore it is imperative that case notes are made available and collected for the Coding department in a timely fashion.
The post holder will be required to undergo intensive Clinical Coder training which will involve a minimum 21 day Standards Course and successfully pass an internal assessment after 12 months.
About us
We are a people business - where every member of staff matters and can make a difference. Patients are at the heart of everything we do. Joining University Hospitals Plymouth NHS Trust means becoming part of a team of dedicated staff, who are committed to leading the way through innovation, clinical excellence and great customer care. The Trust has great opportunities for career development in a highly progressive working environment. We offer all of this in a vibrant, modern city with a historic reputation for adventure. PLEASE NOTE THAT ALL COMMUNICATION WILL BE ELECTRONIC, PLEASE CHECK YOUR EMAIL ACCOUNT REGULARLY. If you have any issues with applying online and need additional support including reasonable adjustments with the application process please contact the recruitment team on 01752 432100. We recognise that work life balance is important for our colleagues and so we invite requests from applicants around less than full time/flexible working for our advertised roles. Please contact the recruiting manager to discuss this prior to your application submission. We commit to giving this full consideration in each case. We encourage people from diverse backgrounds to apply for our roles, as diversity strengthens our teams. It is sometimes necessary to close vacancies before the closing date. If you have not heard from us within 4 weeks of the closing date, please assume that you have not been shortlisted.
Job description
Job responsibilities
PRIMARY DUTIES & AREAS OF RESPONSIBILITY
To train in the administrative aspect of clinical coding
To collect and return case notes to wards in a timely manner.
To trace all case notes into the coding office using the hospital computer system (iPM)
To open and trace in post and file any loose papers into case notes.
To answer telephone queries.
To request case notes from Central Records Library.
To locate and collate missing source material e.g missing case notes.
To liaise with all levels of staff when case notes cannot be located.
To request case notes from peripheral sites as requested or collect from Medical secretaries and other departments within the hospital.
Trainee Clinical Coder
On successful completion of administrative training (approx. 2weeks) the post holder will commence the Trainee Clinical Coder role training.
Trainee
To undergo intensive Clinical Coder training for a minimum of 12 18 months. The post holder will be required to attend a Clinical Coding Standards Course for a minimum of 21 days. The post holder will be required to pass an internal assessment (90% pass mark), on successful completion of assessment the post holder will progress to Band 4
To be fully conversant with the relevant publications of International Classification of Diseases (ICD10) and Classification of Surgical Operations and Procedures (OPCS4).
To critically examine the clinical information required assigning the national codes in accordance with the national guidelines.
To extract, analyse, translate and data enter patient records.
To liaise with consultants, junior medical staff, business managers, information analysts, finance staff, medical secretaries and ward administration staff to address any queries arising during the abstraction process.
To ensure adherence to local procedures for clinical coding relating to individual specialties.
COMMUNICATIONS & WORKING RELATIONSHIPS
- Deputy Head of Performance
- Clinical Coding Service Manager
- Clinical Coding staff
- Ward staff
- Clinical staff
- Central Records Library staff
OTHER
To undertake any other duties as required by the Clinical Coding Service Manager.
Maintain personal and professional developments to meet the changing demands of the job.
Adhere to policy and recommendations relating to data security and confidentiality.
To be familiar with and adhere to the Health and Safety policy and other Trust policies and procedures.
This role will involve prolonged concentration and use of VDU.
All Job Holders are required to
- Work to the Trust values - Put patients first, Take ownership, Respect others, be positive.
- Adhere to Trust policies and procedures, e.g. Health and Safety at Work, Equal Opportunities etc.
- Maintain personal and professional development to meet the changing demands of the job, participate in appropriate training activities and encourage and support staff development and training.
- Attend statutory, essential and mandatory training.
- Respect the confidentiality of all matters relating to their employment and other members of staff. All members of staff are required to comply with the requirements of the Data Protection Act 1998.
- Comply with the Corporate Governance structure in keeping with the principles and standards set out by the Trust.
- Comply with the codes of professional conduct set out by the professional body of which registration is required for the post.
- Ensure they are familiar with the Risk Management Framework, follow policies, procedures and safe systems of work, make known any hazards or risks that they identify and take all necessary actions to reduce risk.
- Ensure the welfare and safety of children within their care. This includes staff who come into contact with children and families in the course of their work as well as those staff who have a specific role with children and families.
- Ensure they attend Child Protection training at the appropriate level within the specified time frame.
- Staff must comply with Safeguarding Policies and Procedures in order to promote safeguarding and prevent abuse to vulnerable people using Trust services.
- Maintain the prevention and control of infection and fully comply with all current Trust Infection Control policies and procedures.
- Take responsibility for any records that they create or use in the course of their duties, in line with the Public Records Act and be aware that any records created by an employee of the NHS are public records and may be subject to both legal and professional obligations.
Job description
Job responsibilities
PRIMARY DUTIES & AREAS OF RESPONSIBILITY
To train in the administrative aspect of clinical coding
To collect and return case notes to wards in a timely manner.
To trace all case notes into the coding office using the hospital computer system (iPM)
To open and trace in post and file any loose papers into case notes.
To answer telephone queries.
To request case notes from Central Records Library.
To locate and collate missing source material e.g missing case notes.
To liaise with all levels of staff when case notes cannot be located.
To request case notes from peripheral sites as requested or collect from Medical secretaries and other departments within the hospital.
Trainee Clinical Coder
On successful completion of administrative training (approx. 2weeks) the post holder will commence the Trainee Clinical Coder role training.
Trainee
To undergo intensive Clinical Coder training for a minimum of 12 18 months. The post holder will be required to attend a Clinical Coding Standards Course for a minimum of 21 days. The post holder will be required to pass an internal assessment (90% pass mark), on successful completion of assessment the post holder will progress to Band 4
To be fully conversant with the relevant publications of International Classification of Diseases (ICD10) and Classification of Surgical Operations and Procedures (OPCS4).
To critically examine the clinical information required assigning the national codes in accordance with the national guidelines.
To extract, analyse, translate and data enter patient records.
To liaise with consultants, junior medical staff, business managers, information analysts, finance staff, medical secretaries and ward administration staff to address any queries arising during the abstraction process.
To ensure adherence to local procedures for clinical coding relating to individual specialties.
COMMUNICATIONS & WORKING RELATIONSHIPS
- Deputy Head of Performance
- Clinical Coding Service Manager
- Clinical Coding staff
- Ward staff
- Clinical staff
- Central Records Library staff
OTHER
To undertake any other duties as required by the Clinical Coding Service Manager.
Maintain personal and professional developments to meet the changing demands of the job.
Adhere to policy and recommendations relating to data security and confidentiality.
To be familiar with and adhere to the Health and Safety policy and other Trust policies and procedures.
This role will involve prolonged concentration and use of VDU.
All Job Holders are required to
- Work to the Trust values - Put patients first, Take ownership, Respect others, be positive.
- Adhere to Trust policies and procedures, e.g. Health and Safety at Work, Equal Opportunities etc.
- Maintain personal and professional development to meet the changing demands of the job, participate in appropriate training activities and encourage and support staff development and training.
- Attend statutory, essential and mandatory training.
- Respect the confidentiality of all matters relating to their employment and other members of staff. All members of staff are required to comply with the requirements of the Data Protection Act 1998.
- Comply with the Corporate Governance structure in keeping with the principles and standards set out by the Trust.
- Comply with the codes of professional conduct set out by the professional body of which registration is required for the post.
- Ensure they are familiar with the Risk Management Framework, follow policies, procedures and safe systems of work, make known any hazards or risks that they identify and take all necessary actions to reduce risk.
- Ensure the welfare and safety of children within their care. This includes staff who come into contact with children and families in the course of their work as well as those staff who have a specific role with children and families.
- Ensure they attend Child Protection training at the appropriate level within the specified time frame.
- Staff must comply with Safeguarding Policies and Procedures in order to promote safeguarding and prevent abuse to vulnerable people using Trust services.
- Maintain the prevention and control of infection and fully comply with all current Trust Infection Control policies and procedures.
- Take responsibility for any records that they create or use in the course of their duties, in line with the Public Records Act and be aware that any records created by an employee of the NHS are public records and may be subject to both legal and professional obligations.
Person Specification
Knowledge & Experience
Essential
- oDemonstrable experience of anatomy and physiology o Proven knowledge and experience in the use of medical terminology oGood keyboard skills. oGood proven knowledge of Microsoft Office software
Desirable
- Proven evidence of working with clinical data oDemonstrable experience of working in a large clinical setting. o Proven knowledge in the use of clinical based computerised systems oProven evidence of working with clinical data.
Qualifications
Essential
- oEducated to GCSE standard or equivalent in Maths and English oMinimum grade A-C or equivalent demonstrable experience
Desirable
- Educated to GCSE standard in a science subject Minimum grade A-C
Aptitude & Abilities
Essential
- Good communication skills, written and verbal, with ability to demonstrate fluency, clarity and effectiveness at all levels. ?Accuracy and attention to detail is essential. ?Used to changing priorities and tight deadlines ?Ability to work well within a busy environment. ?Ability to maintain confidentiality to the highest degree ?Team Worker.
Other Factors
Essential
- oWill spend long periods sitting at a desk and using a computer in a quiet environment. oWill require long periods of concentration
Person Specification
Knowledge & Experience
Essential
- oDemonstrable experience of anatomy and physiology o Proven knowledge and experience in the use of medical terminology oGood keyboard skills. oGood proven knowledge of Microsoft Office software
Desirable
- Proven evidence of working with clinical data oDemonstrable experience of working in a large clinical setting. o Proven knowledge in the use of clinical based computerised systems oProven evidence of working with clinical data.
Qualifications
Essential
- oEducated to GCSE standard or equivalent in Maths and English oMinimum grade A-C or equivalent demonstrable experience
Desirable
- Educated to GCSE standard in a science subject Minimum grade A-C
Aptitude & Abilities
Essential
- Good communication skills, written and verbal, with ability to demonstrate fluency, clarity and effectiveness at all levels. ?Accuracy and attention to detail is essential. ?Used to changing priorities and tight deadlines ?Ability to work well within a busy environment. ?Ability to maintain confidentiality to the highest degree ?Team Worker.
Other Factors
Essential
- oWill spend long periods sitting at a desk and using a computer in a quiet environment. oWill require long periods of concentration
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Additional information
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
