Job summary
Clinical Coders -are highly trained specialists and we have a vacancy we are looking to
recruit to.
A clinical coder extracts relevant information from patients medical
records, translates the diagnoses and procedures into codes using standard
national classifications and then records the information onto the Hospital
Patient Administration System. The Coding Team also play a critical role in
ensuring that the Trust receives appropriate income for patients treated.
The Coding Team also play a critical role in ensuring that the Trust
receives appropriate income for patients treated.
The Coding Team
also play a critical role in ensuring that the Trust receives appropriate
income for patients treated.
Previous experience is not essential, we will train you, however
applicants must have the following experience and attributes:-
- Experience of working in a health care environment
- Knowledge of clinical / medical
terminology
- Respect for confidentiality
- Attention to detail
- Ability to work in a team
- Ability to use Microsoft applications
- Appreciation of deadlines
- Ability to maintain and develop own
skills and knowledge
- Flexibility
- Self-Motivation
The successful candidate will be offered a structured training
programme.
Our Trust recognises the vital contribution of our
coding team to our overall Trust performance and regards our team as pivotal to
our future performance.
Main duties of the job
Key Responsibilities
- Screen medical records, discharge summaries, histopathology results and other data sources to extract clinical information relevant to a patients episode of care.
- Apply independent judgement in the interpretation, transposition and sequencing of clinical data adhering to national rules and conventions.
- Code all patient episodes using a computerised encoding system supported by International Classification of Diseases (ICD 10) & Office of the Population of Censuses and Surveys (OPCS 4) coding manuals.
- Ensure data is entered accurately into the Patient Administration System within national defined deadlines.
- Regularly required to access and read patient case notes where the content can be distressing.
- Adhere to local coding protocols/procedures on all sites.
- Provide cover for the Clinical Coding Team during periods of absence and where vacancies are held.
- Routinely contact medical secretaries, health care records staff and ward personnel to access case notes for coding purposes using a variety of communication skills i.e. email, face to face, telephone.
- Access clinical information electronically from the PAS discharge letter module and clinical information systems.
- Identify inadequate source documentation and communicate with relevant health care professionals to rectify this.
- Raise any coding queries/questions requiring resolution with the Clinical Coding Divisional Lead.
About us
We provide care and support to over a million people in
Wakefield and Kirklees in their homes, community settings and across our
three hospital sites at Pontefract, Dewsbury and Pinderfields (Wakefield).
Always striving for excellence, we are at the forefront of
innovation and research, and we invest in teaching and the development of our
workforce.
We live by our values of caring, improving, being respectful
and maintaining high standards. We listen and learn because we aim to make Mid
Yorkshire the best place to work and receive care.
We value diversity and welcome talent and enthusiasm
irrespective of age, disability, neurodivergence, sex, gender identity and
gender expression, race or ethnicity, religion or belief, sexual orientation,
or other personal circumstances including providing unpaid carers support to
someone with a health and care need. As ethnic minority groups, members of the
LGBTQ+ community, and people with a disability/neurodivergence are currently
under-represented across the organisation, we encourage applications from
members of these groups. We have policies and procedures to ensure all
applicants are treated fairly and consistently.
We are proud of our staff networks - who offer valuable
guidance and feedback from those with lived experience.
We have a clear vision and you could be part of this! If
you share our values and you want to make a difference to the lives of our
patients and their families and carers, we would love to hear from you.
Job description
Job responsibilities
- The Clinical Coding Department is responsible for the accurate and timely recording of clinical data to support the Trusts clinical and business requirements and for regional and National Health Service statistics.
- The post holder will be required to work as a member of a team to provide an efficient clinical coding service working to established systems and procedures
- To screen medical records, discharge summaries and other data sources to extract clinical information relevant to a patients episode of care.
- To code all patient episodes using clinical terms computerised encoding system supported by International Classification of Diseases (ICD 10) and Office of the Population of Censuses and Surveys (OPCS 4) manuals.
- Ensure data is entered accurately into the Patient Administration System (PAS) within nationally defined deadlines.
Job description
Job responsibilities
- The Clinical Coding Department is responsible for the accurate and timely recording of clinical data to support the Trusts clinical and business requirements and for regional and National Health Service statistics.
- The post holder will be required to work as a member of a team to provide an efficient clinical coding service working to established systems and procedures
- To screen medical records, discharge summaries and other data sources to extract clinical information relevant to a patients episode of care.
- To code all patient episodes using clinical terms computerised encoding system supported by International Classification of Diseases (ICD 10) and Office of the Population of Censuses and Surveys (OPCS 4) manuals.
- Ensure data is entered accurately into the Patient Administration System (PAS) within nationally defined deadlines.
Person Specification
Experience
Essential
- Worked in a health care environment.
- General office duties.
- Experience of decision making by own initiative and liaising with colleagues.
Desirable
- Experience of working in an acute healthcare setting.
- Application of the rules and conventions of clinical coding.
Knowledge and Awareness
Essential
- Good knowledge of clinical/medical terminology.
- Good knowledge and use of information / informatics systems.
- Knowledge of the importance of confidentiality, the Data Protection Act and Caldicott principles.
- If established coder and post coding standards - must have up to date refresher and experience in 4.10 OPCS.
Desirable
- Knowledge of clinical coding requirements and standards.
- Knowledge of anatomy and physiology.
- Knowledge of hospital and / or clinical information systems.
Personal Attributes
Essential
- Effective Team player.
- A flexible approach to working hours.
- Ability to maintain and develop own skills and knowledge.
- Adaptable to change.
Other factors
Essential
- Ability to use a PC for significant periods of time.
- IT literate and able to troubleshoot.
- Good interpersonal and communication skills.
Skills and Abilities
Essential
- Able to use basic Microsoft applications i.e., word, excel.
- Good levels of numeracy and literacy skills.
- Ability to extract information from source records and translate into different electronic formats.
- Ability to work to a high degree of accuracy and attention to detail.
- Excellent interpersonal communication skills, written and verbal.
- Ability to work on own initiative to prioritise and plan workloads under pressure to meet deadlines.
Qualifications
Essential
- Minimum A level qualification or equivalent qualification or equivalent knowledge.
Desirable
- Qualification or experience in science or healthcare environment.
- National Clinical Coding Qualification.
- European Computer Driving Licence (ECDL)
Person Specification
Experience
Essential
- Worked in a health care environment.
- General office duties.
- Experience of decision making by own initiative and liaising with colleagues.
Desirable
- Experience of working in an acute healthcare setting.
- Application of the rules and conventions of clinical coding.
Knowledge and Awareness
Essential
- Good knowledge of clinical/medical terminology.
- Good knowledge and use of information / informatics systems.
- Knowledge of the importance of confidentiality, the Data Protection Act and Caldicott principles.
- If established coder and post coding standards - must have up to date refresher and experience in 4.10 OPCS.
Desirable
- Knowledge of clinical coding requirements and standards.
- Knowledge of anatomy and physiology.
- Knowledge of hospital and / or clinical information systems.
Personal Attributes
Essential
- Effective Team player.
- A flexible approach to working hours.
- Ability to maintain and develop own skills and knowledge.
- Adaptable to change.
Other factors
Essential
- Ability to use a PC for significant periods of time.
- IT literate and able to troubleshoot.
- Good interpersonal and communication skills.
Skills and Abilities
Essential
- Able to use basic Microsoft applications i.e., word, excel.
- Good levels of numeracy and literacy skills.
- Ability to extract information from source records and translate into different electronic formats.
- Ability to work to a high degree of accuracy and attention to detail.
- Excellent interpersonal communication skills, written and verbal.
- Ability to work on own initiative to prioritise and plan workloads under pressure to meet deadlines.
Qualifications
Essential
- Minimum A level qualification or equivalent qualification or equivalent knowledge.
Desirable
- Qualification or experience in science or healthcare environment.
- National Clinical Coding Qualification.
- European Computer Driving Licence (ECDL)
Additional information
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
