Senior Clinical Coder (

Job description

Job responsibilities

The Princess Alexandra Hospital NHS Trust (PAHT) provides a full range of general acute, outpatient and diagnostic services at The Princess Alexandra Hospital in Harlow, the Herts and Essex Hospital in Bishop’s Stortford, and St Margaret’s Hospital in Epping.

We employ 3,500 staff and serve a local population of around 350,000 people living in west Essex and east Hertfordshire, centred on the M11 corridor and the towns of Harlow, Bishop’s Stortford and Epping. Our extended catchment area incorporates a population of up to 500,000 and includes the areas of Hoddesdon, Cheshunt and Broxbourne in Hertfordshire.

Our Values

The Princess Alexandra Promise to our patients as identified by our 3 values which will contribute to improving our patient experiences:

Patient at heart – Always holding the patient and their wellbeing at the centre of our thoughts and efforts

Everyday excellence – Sharing and celebrating our successes, being honest when we get it wrong, giving us the ability to learn from both

Creative collaboration – Knowing strength comes from diversity, we combine our experiences, skills and talents, working together to find new and better ways to care

The Trust believes in investing in all our staff and rewarding high standards of care whilst building for excellence and in return we expect our staff to uphold the Trust values to the highest level.

Job overview

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 senior Clinical Coder, guided by occupational policies, assisting coders with complex coding queries, providing expert advice to other departments on coding issues.

To support in the leading of the coding team assigned to support a specific area of Clinical work. 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.

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.

Scope and range

• Support Clinical Coding Specialist Health Group Lead to ensure targets are met within the specified timescale.
• Support Clinical Coding Specialist Health Group Lead in all aspects to ensure smooth running of the department.
• Work according to Trust / National policies.
• Mentor coders for accuracy and consistency of Coding. Awareness of Data Protection Act; always maintain Patient Confidentiality.
• Extract, analyse, and translate complex clinical information from patient cases notes allocating accurate diagnosis & operational procedure codes. Code finished consultant episodes for all sites of the Trust.
• 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.

Main duties of the job

• To identify uncoded activity be reviewing the daily discharges reports / uncoded reports
• Using clinical documentation on AlexHealth to identify, analyse, extract and interpret complex information relating the patients stay.
• Using other source documentation and systems to identify, analyse, extract and interpret complex information relating to the patients stay.
• Using coding tools (Coding Standards, 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. Ophthalmology, Endoscopy, and other clinical systems in use at the Trust, to obtain other information to inform the coding process and to ensure the completeness and accuracy of coding.
• 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 4.10 Office ICD-10) or any classification that may be implemented in the future.
• To enter coded clinical data onto the Trust encoder (Solventum Medicode 360) ensuring accuracy, completeness and timeliness at all times as failure to code episodes accurately will have a direct effect on Trust reporting.
• 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 Data Quality team, while ensuring the Assistant Clinical Coding Manager is aware.
• 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 the departmental targets are met and to advise the team leader of any hindrance to the achievement of these targets, providing support and supervision to more junior coders.
• 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.
• To support the Clinical Coding Specialist Health Group Lead in motivating all staff in the Coding Team 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.

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.

Person Specification

Qualifications

Essential

• Accredited Clinical Coder qualification or equivalent experience
• Attainment of the Clinical coding foundation Course
• Evidence of attendance to a Clinical Coding refresher course, within the last 2 years

Desirable

• Evidence of post graduate qualification or equivalent experience in managing a performance output-based service
• Evidence of attendance on Clinical coding speciality workshops, with the last 2 years
• Leadership and Management qualification (training will be given)
• Approved Clinical Coding Auditor or Trainer Qualification
• Degree in an anatomy or physiology related subject

Experience

Essential

• Evidence of Continuing professional Development
• Demonstrable in-depth specialist Clinical Coding experience across a wide range of Specialities, in an Acute Trust setting.
• Experience of using Patient Administration systems and encoding software

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.

Employer details

Employer name

The Princess Alexandra Hospital NHS Trust

Address

The Princess Alexandra Hospital

Harlow

Essex

CM20 1QX

Employer's website

https://www.pah.nhs.uk (Opens in a new tab)