North Tees & Hartlepool NHS Foundation Trust

Clinical Coding Auditor

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Job summary

As the Clinical Coding Auditor, you will be responsible for delivering the Trusts Internal Clinical Coding Audit and Assurance Programme, which has been devised as part of a wider Clinical Coding Audit Framework. The role contributes to ensuring the clinical coding, produced by the coding team, accurately reflects all national rules, conventions and datasets. A key part of the role is carrying out internal feedback of audit results and findings, to ensure that all relevant personnel (both coding and clinical) are informed of the need for change and understand the way forward.

The successful candidate will also act as a key coding link for Clinical Teams, reporting audit findings and providing recommendations directly to the relevant specialties.

In order to be a Clinical Coding Auditor candidates must have passed the National Clinical Coding Qualification to become an Accredited Clinical Coder.

Main duties of the job

The post-holder will have responsibility for the delivery of a comprehensive audit programme to the Trust's Clinical Coding Team. They will ensure that clinical coding accurately reflects all national rules, conventions and datasets, keeping abreast of national clinical coding developments and cascading this knowledge to the Clinical Coding Team. The post-holder will carry out the annual Data Security and Protection Toolkit audit, complemented by a formal annual report.

The post-holder will advise on and assist in the implementation of any new guidance and ensure that all local policies are updated in line with national standards.

As well as maintaining and developing their own professional and personal skills, the post-holder will be responsible for the development and implementation of individual mentorship and audit programmes to ensure that coders are confident and effective in their roles and to facilitate the achievement of the necessary quality standards and information governance requirements.

About us

At North Tees & Hartlepool NHS Foundation Trust our main priority is, and always will be, to provide safe and high quality care to our patients every day; the kind of care we would want for ourselves and our loved ones. We want our organisation to be the best place to work with the right staff, in the right roles, at the right time, to ensure we deliver exceptional patient care and experience.

We will support staff through providing an inclusive and supportive workplace with health and well-being initiatives, staff benefits and opportunities for personal and professional development. Staff recognition is very important to us; as well as performance reviews and appraisals, we recognise staff through Star and Team of the month, colleague recognition - a note of thanks, Managers Awards, Shining Stars and Service Awards.

We support the Making Every Contact Count approach to behaviour change in the promotion of health and wellbeing of individuals and communities.

We recruit for values and "Together we are North Tees & Hartlepool"

Date posted

06 January 2025

Pay scheme

Agenda for change

Band

Band 6

Salary

£37,338 to £44,962 a year pa

Contract

Permanent

Working pattern

Full-time

Reference number

345-COR6843962

Job locations

University Hospital of North Tees

Hardwick Road

Stockton on Tees

TS19 8PE

Job description

Job responsibilities

Deliver the Trusts Internal Clinical Coding Audit and Assurance Programme, which has been devised as part of a wider Clinical Coding Audit Framework to support key work-streams within the organisation;

During the audit process, abstract clinical information from the electronic patient record to translate into diagnostic (ICD10) and operative (OPCS4) codes in an accurate manner, applying national and international classification rules and conventions;

Act as a key coding link for Clinical Teams, reporting audit findings and providing recommendations directly to the relevant specialties. Monitor changes made following feedback;

Support the implementation of an internal feedback mechanism following audits to ensure that all relevant personnel (both coding and clinical) are informed of the needs for change and understand the way forward;

If required, ensure incorrect coded data is fed back to the relevant coders in a timely manner, prior to the freeze date, to ensure the data is correct at the final download;

Support the Clinical Coding Training and Audit Manager by informing training needs identified during audits;

Provide cover for certain colleagues in the Clinical Coding Team during periods of absence. This may include attending meetings and communicating with the management and clinical Teams;

Carry out the Revenue Improvement Solution (RIS) monthly documentation reviews, when the RIS Assistant is on leave, or provide assistance when the need arises;

Work with clinicians to ensure they understand the coding process and its limitations, discuss complex clinical information and convey coding standards and requirements in language understandable by clinicians;

Abstract and analyse complicated patient clinical records, applying the clinical coding rules and conventions, using own judgement;

Benchmark the Trusts clinical-coded data against that produced by other NHS organisations; in order to ascertain and explain differences within performance indicators, informing the Trusts clinical-coding training plan;

Monitor the quality of coded data via a suite of reports prior to external submission of Trust data and support the improvements within key performance indicators relating to national coding standards;

Monitor data-quality and clinical-coding standards in line with local and national guidance and take a lead on the departments clinical-coding query mechanism such as seeking relevant guidance from the Classifications Service;

Accountable for accuracy of own audited data, and for sharing newly acquired knowledge from clinicians;

Keep abreast of all new national guidance in relation to clinical-coding practices and ensure own coding skills are kept up to date;

Strictly adhere to standards relating to World Health Organisation classification ICD-10 and NHS Digital classification OPCS-4;

Ensure all ICD/OPCS books are kept up to date with latest guidance;

Implement any changes to national guidance. Also, provide support to both the Clinical Coders and Clinical Teams to implement any changes.

Seek guidance from training and audit team, coding managers, and clinicians, if required;

Respond to queries and advice requests from Clinical Coding colleagues and other interested parties;

Assist in both the development and maintenance of local departmental Clinical Coding Policies and Procedures;

Work towards achieving the objectives discussed and agreed with your line manager and included in your Personal Development Plan (PDP). These objectives will reflect the objectives of the department;

Undertake all mandatory and non-mandatory training associated with attaining and maintaining Accredited Clinical Coder Auditor status.

Undertake all appropriate training, as deemed necessary by the Training and Audit Manager;

Participate in the Knowledge Skills Framework process for other staff and participate in the appraisal of staff within the clinical-coding team, providing motivational support to aid staff development

High levels of autonomy in prioritising own workload and co-ordinating departmental workload to meet deadlines;