Senior Clinical Coder

Job description

Job responsibilities

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.

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

• 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)