Clinical Coding Auditor (XN06)

Job description

Job responsibilities

JOB DESCRIPTION AND PERSON SPECIFICATION

1. JOB DETAILS

Job Title: Clinical Coding Auditor

Reports to: Clinical Coding Analyst & Trainer

Band: 6

Unit/Department: Clinical Coding

Location[1]: Cross-site

AfC Job No: 2801e

2. JOB PURPOSE/SUMMARY

The Clinical Coding Auditor has responsibility for assessing and monitoring the quality of coding produced by the department. They provide feedback and guidance to staff and implement any systems necessary to ensure continuing improvement.

The post-holder must be a nationally approved auditor (registered with NHS England Terminology and Classifications Service) or willing to obtain the qualification within 12 months of appointment. They must be able to produce audit reports suitable for all levels of management within the Trust and to provide expert advice as necessary.

Coding Auditors are also involved in the process of external audits, signing off any errors, challenging external auditor decisions when appropriate and helping to implement any recommendations as necessary.

Audit work impacts on all Clinical CSUs as the auditor will aim not only to address incorrect coding but work with clinical teams around documentation. Highlighting and correcting errors will have a financial implication for the organisation; it is essential the auditor works with the finance team and ICB to ensure notice periods are adhered to.

The individual will be responsible for making recommendations for service improvement and implementing a comprehensive audit policy document for the department, researching and implementing local clinical coding policies and maintaining these policies to ensure continued accuracy and consistency of the clinically coded information.

The post-holder will be responsible for assisting with external audits; there are generally one to two of these per year. Each year, they must compile and submit a more extensive audit of coding in the Trust (200 episodes).

Clinical Coding is the driver behind nationally collected information and the correct reimbursement of funds for activity undertaken in LTHT. It is essential that the clinical coding is accurate.

The Auditors role is vital for the organisation to improve and then maintain high standards of coded information.

The effects of improving the Clinical Coding are long reaching as it will affect all Clinical CSUs, Finance and Informatics, requiring the individual to have extensive knowledge of Acute Hospital Trusts and the external organisations involved.

The individual will be responsible for the safe and efficient use of specialist Clinical Coding equipment for use by themselves and others within the clinical coding function.

A key responsibility for the individual will be to provide training for the department through audit, ensuring that the team are adhering to National standards and working through errors with the team to understand the root cause.

4. PRINCIPAL DUTIES & AREAS OF RESPONSIBILITY

Audits the work of the department, in line with national and local coding standards and the auditor code of conduct.

To provide expert advice, training and feedback to the Clinical Coding team.

Provides input into reviews of coding local policies to ensure that they are comprehensive and meet national standards and guidelines.

Develops and maintains a comprehensive internal audit plan, in line with the needs of the department and wider organisation.

Gives detailed audit feedback, producing professional reports, fit for presentation at board-level. Agrees recommendations with the management team.

Is involved in giving direct feedback to the targets of all audits, tactfully and constructively.

Carries out (yearly) an extensive audit of coding produced by the team, for inclusion in the Trusts Information Governance Toolkit submission.

Carries out audits on individual Coders when requested, to support internal management processes.

Performs audits to assess whether Trainee Coders have met the accuracy requirements for progression.

Assists with preparation for external audits (NHSPS assurance and ICB-requested). Challenges external auditor decisions when appropriate.

Uses all available tools to identify and monitor data quality improvements, reporting findings to the management team.

Keeps a personalised audit logbook in line with CCAP requirements, to evidence continuing professional development and to maintain approved auditor status.

Assists with the day-to-day work of the department and carries out any other appropriate duties as and when required by the management team.

The post holder will have excellent communication skills to be able to impart complex clinical coding information to groups and individuals with no Clinical Coding background such as Clinicians and Business Managers.

The post holder will act as lead specialist for the department, the individual will be able to use their own discretion on how to undertake activities within the Auditor role. The Individual will implement programs of audit and the audit process. Based on the needs of the department and the individual the Auditor is able to propose changes in working practices and procedures to improve the quality of the Clinical Coding.

Experience of using the Microsoft Office suite, including Word, Excel, PowerPoint and Outlook.

The individual will be responsible for the testing of upgrades to the Medicode (encoder Software) prior to implementation by Daedalus (PAS software provider).

Demonstrated enhanced data extraction skills in order to correctly reflect/interpret clinical information into a coded format and accurately input the coded information onto the encoder software to ensure correct re-numeration of funds for LTHT. A highly developed eye for detail is essential.

Develop and maintain audit database for the Clinical Coding team.

The individual will be responsible for bringing together the information required to develop a suite of reports to monitor areas where additional training has been provided. The individual will be required to regularly create reports through national benchmarking software to assess LTHT performance against peer hospital groups.

Expert knowledge of data protection issues in coding, including a familiarity with the requirements of the Data Protection Act, the Freedom of Information Act and the Caldicott principles.

Communication Skills - The auditor, will be responsible for providing audit feedback to a wide range of individuals both from within coding and the wider organisation. This will require highly developed communication skills to feedback complex clinical coding information to individuals, who may or may not have performed to expected standards. The Auditor must be able to communicate sensitively and empathically in order to make a potentially negative conversation into a positive learning experience.

The Auditor, when feeding back to the wider organisation, must have a highly developed understanding of what is causing errors in order to feed back to CSUs or medical teams to rectify these issues.

The post-holder must be able to work constructively with the team in order to improve quality.

They must be able to deliver effective verbal and written feedback to a wide range of audiences, including Consultants, Coders, local and senior management.

Teamwork - The auditor works closely with the Clinical Coding Trainer to establish and implement improvement programmes for the department. The Auditor will be required to work closely with triumvirates to understand where additional audits may be required and based on the results the wider implications of making changes in these areas, such as financial or against national benchmarking.

Analytical Skills - Must be an expert in analysing medical documentation. Able to break down complex problems and interpret the National Coding Standards in a consistent manner.

The individual must be able to analyse information on national benchmarking to understand where LTHT stands with the peer group of acute Trusts and to review and understand if the Trust is outlying in any areas.

Displays Good Judgement - Must be able to select the most appropriate resolutions to complex problems (e.g. coding of non-directly classifiable conditions / procedures, seemingly conflicting coding guidance), based on a variety of different possibilities. The reasoning must then be explained clearly and effectively.

Person Specification

Qualifications

Essential

• Must be an Accredited Clinical Coder (ACC), having passed the National Clinical Coding Qualification (NCCQ).
• Must have attended a National Coding Standards Course or Standards Refresher Course within the past three years.

Desirable

• Must be an Approved Clinical Coding Auditor, registered with NHS England (or willing to work towards this).

Experience

Essential

• Must demonstrate an expert-level knowledge of the ICD-10 classification and associated national standards for England.
• Must demonstrate an expert-level knowledge of the OPCS-4 classification and associated national standards for England.
• Must have extensive experience of working in an acute trust as a senior-level coder over multiple complex specialities.
• Must have demonstrated an ability to write professional reports and to communicate effectively with a wide range of audiences (individuals and groups).
• Must have experience of identifying and investigating anomalous results, providing solutions and monitoring their effectiveness.

Desirable

• Have previous experience working as a Coding Auditor in an acute trust.
• Experience of using 3M Medicode, including the coding, reporting and audit functions
• Experience of using the Daedalus PatientCentre PAS or similar systems.
• Experience of directing the work of small teams for ad-hoc projects
• A good understanding of the workings of LTHT; its services, structure, objectives and policies

Skills & Behaviours

Essential

• Displays consistently good analytical and judgement skills. Able to correctly interpret and apply highly complex rules and standards.
• Gives feedback clearly but tactfully and with regard to the likely consequences of the results.
• Shows enthusiasm for the work of the team. Keeps up to date with changes in the field and develops / maintains professional contacts in other Trusts.
• Works with others from outside the department and conducts themselves in a professional and friendly manner.

Other criteria

Essential

• Good organisational skills, in order to manage own workload (structured and ad-hoc) to achieve departmental deadlines.
• Excellent communication skills - able to provide complex information to a wide range of audiences.

Employer details

Employer name

Leeds Teaching Hospitals

Address

Leeds General Infirmary

Great George Street

Leeds

LS1 3EX

Employer's website

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