Job summary
The purpose of the post is to ensure that all Inpatient, Day case and Outpatient episodes of care are coded at the end of each episode within an agreed timeframe and to a high standard of accuracy. The case notes are extremely complex in nature and the post requires long periods of concentration and careful examination. The post holder will deal with enquiries which may be complex in nature. The post holder will locate case notes and liaise with support service and ward staff to ensure that clinical notes are made available for coding.
Main duties of the job
This job requires interaction with clinicians and support services staff at all Powys THB locations. There is a requirement to maintain complex professional knowledge, and the post holder will need to engage and interact with colleagues at an all Wales level and attend ongoing training.
The Clinical Coding team forms part of the Information department as coding plays a vital role in the statutory reporting process. As part of a small clinical coding team the post holder will support other clinical coders and act as a mentor sharing best practice and experience. All clinical coders within Powys THB will gain experience and knowledge of all coding activities undertaken throughout Powys.
The ability to speak Welsh is desirable for this post; Welsh and/or English speakers are equally welcome to apply.
About us
Being the smallest Heath Board in Wales means that you won't get lost in the crowd. Everybody at Powys Teaching Health Board is valued for the contribution they make to our varied and diverse portfolio of community-based services. Together, we can continue to make a real difference to our patients and build on our unrivalled reputation.
As a supportive and progressive employer, we actively encourage you to carve out a career with us, through a range of development pathways. We're also lucky enough to be situated in one of the most beautiful rural counties in Britain, let alone Wales! Achieving a healthy 'life work' balance is essential, and something we recognise by prioritising your well-being.
To start your journey with us, and to learn more about what we can offer you please visit: https://pthb.nhs.wales/working-for-us/. There you will find information about our benefits and values, read staff experiences and more about what our beautiful county has to offer.
Job description
Job responsibilities
Maintain a high level of knowledge and skills required in the use of coding procedures and conventions, understanding a range of work procedures requiring knowledge of medical terminology, anatomical and physiological terms which will be acquired through work-based training.
- Communicate complex clinical coding rules to medical, clinical and administrative staff.
- Receive, abstract and analyse complex and highly confidential information in the form of individual patient clinical notes and translate into agreed national ICD10 and OPCS codes.
- Use judgement to translate and interpret cases where the procedure undertaken is not readily codable by applying clinical coding conventions.
- Maintain and update case note tracking to ensure that medical staff are aware that individual patient notes are in the process of being coded.
- Input patient information into the Patient Administration System for Powys
- (WPAS) using standard keyboard skills.
- Working without supervision at a given location within Powys THB. The post holder will organise their own day to day work tasks and activities.
- Responsible for updating and maintaining individual reference documentation to ensure that all nationally agreed amendments to coding manuals are acted upon.
- Recommend and comment on proposed changes to national and local variations.
- Follow the policies and procedures put in place nationally and locally for clinical coding.
- Undertake audits and validation of data entered onto WPAS as necessary.
- There is a requirement for the post holder to collect case notes from hospital wards and therefore may have incidental contact with patients.
- Frequent requirement for sitting in a restricted position, reading case notes and inputting into computer.
- Frequent requirement for prolonged concentration when converting information into a national coding structure.
- Frequent indirect exposure to distressing or emotional circumstances through exposure to patient case notes that may hold disturbing photographs and notes about abuse and terminally ill patients.
- The use of VDU is more or less continuous.
You will be able to find a full Job description and Person Specification attached within the supporting documents or please click Apply now to view in Trac.
Job description
Job responsibilities
Maintain a high level of knowledge and skills required in the use of coding procedures and conventions, understanding a range of work procedures requiring knowledge of medical terminology, anatomical and physiological terms which will be acquired through work-based training.
- Communicate complex clinical coding rules to medical, clinical and administrative staff.
- Receive, abstract and analyse complex and highly confidential information in the form of individual patient clinical notes and translate into agreed national ICD10 and OPCS codes.
- Use judgement to translate and interpret cases where the procedure undertaken is not readily codable by applying clinical coding conventions.
- Maintain and update case note tracking to ensure that medical staff are aware that individual patient notes are in the process of being coded.
- Input patient information into the Patient Administration System for Powys
- (WPAS) using standard keyboard skills.
- Working without supervision at a given location within Powys THB. The post holder will organise their own day to day work tasks and activities.
- Responsible for updating and maintaining individual reference documentation to ensure that all nationally agreed amendments to coding manuals are acted upon.
- Recommend and comment on proposed changes to national and local variations.
- Follow the policies and procedures put in place nationally and locally for clinical coding.
- Undertake audits and validation of data entered onto WPAS as necessary.
- There is a requirement for the post holder to collect case notes from hospital wards and therefore may have incidental contact with patients.
- Frequent requirement for sitting in a restricted position, reading case notes and inputting into computer.
- Frequent requirement for prolonged concentration when converting information into a national coding structure.
- Frequent indirect exposure to distressing or emotional circumstances through exposure to patient case notes that may hold disturbing photographs and notes about abuse and terminally ill patients.
- The use of VDU is more or less continuous.
You will be able to find a full Job description and Person Specification attached within the supporting documents or please click Apply now to view in Trac.
Person Specification
Knowledge, Training & Experience
Essential
- Good standard of general education.
- Accredited Clinical Coder qualification or equivalent knowledge and experience of clinical coding. The post holder will be expected to have or work towards this.
- Knowledge of medical terminology acquired through work based training
Technical Skills
Essential
- Computer literate.
- WPAS trained.
- Good analytical and problem-solving skills.
- Knowledge of Data Protection and Caldicott guidelines.
- Knowledge of current national policies relating to clinical coding.
Communication Skills
Essential
- Good organisational, communication and listening skills.
- Ability to explain complex issues around clinical coding in a meaningful manner to all levels of staff.
Skills, Abilities, Knowledge
Essential
- Organised and methodical.
- Ability to work unsupervised.
Other Requirements
Essential
- Team player.
- Ability to travel between hospital sites within Powys.
- Ability to attend training sessions outside of Powys with the possibility of overnight stays.
Desirable
Person Specification
Knowledge, Training & Experience
Essential
- Good standard of general education.
- Accredited Clinical Coder qualification or equivalent knowledge and experience of clinical coding. The post holder will be expected to have or work towards this.
- Knowledge of medical terminology acquired through work based training
Technical Skills
Essential
- Computer literate.
- WPAS trained.
- Good analytical and problem-solving skills.
- Knowledge of Data Protection and Caldicott guidelines.
- Knowledge of current national policies relating to clinical coding.
Communication Skills
Essential
- Good organisational, communication and listening skills.
- Ability to explain complex issues around clinical coding in a meaningful manner to all levels of staff.
Skills, Abilities, Knowledge
Essential
- Organised and methodical.
- Ability to work unsupervised.
Other Requirements
Essential
- Team player.
- Ability to travel between hospital sites within Powys.
- Ability to attend training sessions outside of Powys with the possibility of overnight stays.
Desirable
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.
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).
Additional information
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.
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).
