Job summary
We are looking for a motivated and enthusiastic Accredited Clinical Coder to join our Team.
To provide an efficient and high quality clinical coding service to support the business needs of the Trust, including Clinical Governance, Information Governance and finance by ensuring accurate translation and input of medical terminology.
To act as an expert specialist Clinical Coder, guided by occupational policies, assisting coders with complex coding queries, providing expert advice to other departments on coding issues.
You will be responsible for ensuring that coding deadlines are met , and working with senior staff within the department for ensuring that staff are adhering to national and local coding standards, polices and guidelines.
Ensuring that the mandatory and coding training of staff within the team is up to date, and that performance is at the expected level linking into the annual appraisal process.
Plan service provision within your clinical areas to ensure that the service provided is of the highest standard and that all deadlines are met.
To analyse and extract diagnostic and procedural information from patient case notes and information systems and assign the appropriate code, in accordance with local and national coding practices in an accurate and timely fashion
Main duties of the job
Role to includes day to day supervision of Clinical Coding team, monitoring performance and ensuring targets are met within the specified timescale.
Supporting the Assistant Coding Manager in all aspects to ensure smooth running of the department.
Mentoring junior coders for accuracy and consistency of Coding. To be Aware of Data Protection Act; maintain Patient Confidentiality at all times, and it relation to clinical coding
To Extract, analyse, and translate complex clinical information from patient cases notes allocating accurate diagnosis & operational procedure codes. Code finished consultant episodes on all sites of the Trust.
To Communicate complex coding rules. Liaise with Clinicians/Information/Finance and other departments/agencies.
Work with Divisions , to promote Clinical Coding and the level of clinical information that is required to support the high quality of coding.
Support in the Resolution coding queries from across the Trust
About us
The Princess Alexandra Hospital NHS Trust (PAHT) is proud to care for the communities of West Essex, delivering safe, compassionate, and high-quality services. We are part of the Neighbourhood Wave; a national programme thats changing how care is delivered by focusing on prevention, early support, and more joined-up services across health, social care, and the voluntary sector.
This means were working more closely with local partners to bring care closer to home and support people to live healthier, more independent lives.
Were a supportive and inclusive organisation that values its people. We offer development opportunities, flexible working, and a strong focus on wellbeing. As a Disability Confident and equal opportunities employer, we welcome applicants from all backgrounds and experiences.
Join us and help shape the future of care in West Essex.
Job description
Job responsibilities
Duties and responsibilities
- To identify uncoded activity be reviewing the daily discharges list / uncoded lists
- To visit ward and non-clinical areas to extract the necessary clinical details from case notes to inform the clinical coding process.
- Using other source documentation and systems to identify, analyse, extract and interpret complex information relating to the patients stay
- Using coding tools (Coding Manual, ICD and OPCS classification books, coding clinics and Classification Service resolutions) identify the codes to be applied to each Finished Consultant Episode
- At all times adhering to national standards and local coding policies exercise judgement and initiative in selecting the appropriate clinical codes to ensure that the coding accurately reflects the individual patient episode.
- To access a variety of information systems, e.g. pathology, radiology, and other clinical systems in use in the Trust, to obtain other information to inform the coding process and to ensure the completeness and accuracy of coding by checking results.
- To use own discretion and judgement to analyse often complex information available using coding rules and conventions to translate this information into the appropriate codes as set out by national guidance (OPCS 4 Office ICD-10) or any classification that may be implemented in the future.
- To enter coded clinical data onto the Trust encoder (3M Medicode) ensuring accuracy, completeness and timeliness at all times as failure to code episodes accurately will have a direct effect on Trust income.
- To routinely code a minimum of 40 episodes per day on average.
- To identify data quality queries on the patient information system, for example patients not admitted, transferred and discharged, wrong Consultants and dates and address the issue with the Assistant Clinical Coding Manager.
- To negotiate with clinicians over interpretation of coding guidance, escalating to the Assistant Coding Manager as appropriate.
- To deal with coding queries as and when is necessary throughout the working day and to communicate complex coding rules to medical, clinical, administration staff.
- To be responsible for prioritising the workload of your Team using the uncoded reports available, ensuring that to departmental targets are met and to advise the Assistant Coding Manager of any hindrance to the achievement of these targets, providing support and supervision to more junior coders.
- To work with other staff groups (clinical, managerial and administrative) within a specific division to resolve any coding or classification queries. Communicating complex coding rules and key terms and conventions to these staff groups, working to ensure that the coding reflects the patients’ clinical condition and treatment and that the Income generated (via HRG allocation) is accurate.
- Motivating all staff in the Coding Team and within the divisions by discussion and analysis to ensure that the Clinical documentation and the subsequent Clinical coding is of a high quality To participate in discussions of coding problems and issues with other clinical coders, for example at monthly departmental meetings.
- To demonstrate a high degree of compliance and discipline in accordance with complex changing terminology and their relationship to new surgical techniques and all new changes in the diagnostic field as related to the classifications and medicine.
- Working with the Coding Auditor to ensure coding is accurate by participating in planned and spot check audits in an on-going basis, feeding back results and areas of learning.
- Be responsible for conducting the annual appraisals for staff working in their Team, agreeing objectives and highlighting identified coding training needs to the Assistant Coding Manager.
- Where staff performance is below the required level you will be required to work with the staff member in line with Trust Performance Policy to improve their performance, supporting the Assistant Coding Manager if any formal or informal action is required.
This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.
Additional Information
The role is subject to a 20% recruitment and retention supplement, to be reviewed at 12 months.
Per annum, there will be a 5% high cost area supplement.
Remote / home-working is available for this role.
Job description
Job responsibilities
Duties and responsibilities
- To identify uncoded activity be reviewing the daily discharges list / uncoded lists
- To visit ward and non-clinical areas to extract the necessary clinical details from case notes to inform the clinical coding process.
- Using other source documentation and systems to identify, analyse, extract and interpret complex information relating to the patients stay
- Using coding tools (Coding Manual, ICD and OPCS classification books, coding clinics and Classification Service resolutions) identify the codes to be applied to each Finished Consultant Episode
- At all times adhering to national standards and local coding policies exercise judgement and initiative in selecting the appropriate clinical codes to ensure that the coding accurately reflects the individual patient episode.
- To access a variety of information systems, e.g. pathology, radiology, and other clinical systems in use in the Trust, to obtain other information to inform the coding process and to ensure the completeness and accuracy of coding by checking results.
- To use own discretion and judgement to analyse often complex information available using coding rules and conventions to translate this information into the appropriate codes as set out by national guidance (OPCS 4 Office ICD-10) or any classification that may be implemented in the future.
- To enter coded clinical data onto the Trust encoder (3M Medicode) ensuring accuracy, completeness and timeliness at all times as failure to code episodes accurately will have a direct effect on Trust income.
- To routinely code a minimum of 40 episodes per day on average.
- To identify data quality queries on the patient information system, for example patients not admitted, transferred and discharged, wrong Consultants and dates and address the issue with the Assistant Clinical Coding Manager.
- To negotiate with clinicians over interpretation of coding guidance, escalating to the Assistant Coding Manager as appropriate.
- To deal with coding queries as and when is necessary throughout the working day and to communicate complex coding rules to medical, clinical, administration staff.
- To be responsible for prioritising the workload of your Team using the uncoded reports available, ensuring that to departmental targets are met and to advise the Assistant Coding Manager of any hindrance to the achievement of these targets, providing support and supervision to more junior coders.
- To work with other staff groups (clinical, managerial and administrative) within a specific division to resolve any coding or classification queries. Communicating complex coding rules and key terms and conventions to these staff groups, working to ensure that the coding reflects the patients’ clinical condition and treatment and that the Income generated (via HRG allocation) is accurate.
- Motivating all staff in the Coding Team and within the divisions by discussion and analysis to ensure that the Clinical documentation and the subsequent Clinical coding is of a high quality To participate in discussions of coding problems and issues with other clinical coders, for example at monthly departmental meetings.
- To demonstrate a high degree of compliance and discipline in accordance with complex changing terminology and their relationship to new surgical techniques and all new changes in the diagnostic field as related to the classifications and medicine.
- Working with the Coding Auditor to ensure coding is accurate by participating in planned and spot check audits in an on-going basis, feeding back results and areas of learning.
- Be responsible for conducting the annual appraisals for staff working in their Team, agreeing objectives and highlighting identified coding training needs to the Assistant Coding Manager.
- Where staff performance is below the required level you will be required to work with the staff member in line with Trust Performance Policy to improve their performance, supporting the Assistant Coding Manager if any formal or informal action is required.
This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.
Additional Information
The role is subject to a 20% recruitment and retention supplement, to be reviewed at 12 months.
Per annum, there will be a 5% high cost area supplement.
Remote / home-working is available for this role.
Person Specification
Qualifications
Essential
- National Clinical Coding qualification (degree level)
- Evidence of attendance on Clinical coding speciality workshops, with the last 2 years
- Evidence of attendance to a Clinical Coding refresher course, within the last 2 years
Desirable
- Evidence of post graduate qualification
- ECDL
- Leadership and Management qualification (training will be given)
Experience
Essential
- Experience in managing a performance output-based service
- Demonstrable in-depth specialist Clinical Coding experience across a wide range of Specialities, in an Acute Trust setting
Desirable
- Experience of Clinical Coding Audit
- Leadership and Management experience (training will be given)
Person Specification
Qualifications
Essential
- National Clinical Coding qualification (degree level)
- Evidence of attendance on Clinical coding speciality workshops, with the last 2 years
- Evidence of attendance to a Clinical Coding refresher course, within the last 2 years
Desirable
- Evidence of post graduate qualification
- ECDL
- Leadership and Management qualification (training will be given)
Experience
Essential
- Experience in managing a performance output-based service
- Demonstrable in-depth specialist Clinical Coding experience across a wide range of Specialities, in an Acute Trust setting
Desirable
- Experience of Clinical Coding Audit
- Leadership and Management experience (training will be given)
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.
