Detailed Job Description and Main Responsibilities
Clinical Coding is a highly skilled role. The post holder will attend the Standards Course and undergo specialised formal workshops and on-the-job training/mentoring, to build knowledge and competency levels to convert clinically generated text into a coded format, entering the codes on the Trusts' encoding system. They will work as part of a team responsible for the collation and translation of written diagnostic and procedural information from clinical documentation into internationally recognised codes, OPCS-4 & ICD-10, adhering to the rules agreed by the World Health Organisation. As a trainee, you will be expected to work towards the Accredited Clinical Coder qualification and study independently. Work is supervised by the Training Team & Coding Manager, supported by Accredited Clinical Coding Analysts until an agreed level of competence is reached. Main Responsibilities
Identify from the PAS system episodes to be coded. Extract relevant information regarding diagnosis/procedures/dates from the source document. Ensure from the episode details within the patient record, the finished consultant episode is coded according to the rules of ICD & OPCS, to provide consistent high-quality coding. On a daily basis complete the coding of those patients who have discharged episodes within the Trust PAS, inputting the code to the encoding system, in order to generate information for financial purposes (HRGs), clinical indicators, clinical governance, and local, national and international data. To assign, sequence and input all codes necessary to reflect the patient's total care, using ICD10 and OPCS4. To raise a problem report to identify documentation or episode data errors that impact the achievement of coding quality and completeness. To liaise with Auditors/Trainers to reach a firm decision as to the Diagnosis and Procedure to be coded when advice is required. Utilise the EPR and other relevant data/paper systems to retrieve data to assist in the coding of completed patient episodes. To ensure a high standard of coding quality and timeliness is maintained. To identify and locate the patient records or other relevant data to facilitate the coding of all uncoded episodes on a daily basis, ensuring complete coding of diagnostic and procedure codes to meet deadlines. Give support in the development of any new procedures and systems within the department. Maintain and update as necessary a personal copy of the relevant coding manuals, in accordance with national standards and guidance from the Training Manager & Coding Clinic. To receive training in and acquire skills in new coding schemes. Identify and report Data Quality issues to the Clinical Coding Manager. Work with those you support to develop a collaborative working partnership, which positively contributes to their overall efficiency and role performance. Person Specification
Education & Qualification
Essential Criteria
A level in science/biology. Knowledge of Anatomy & Physiology. Knowledge of Medical Terminology. Evidence of the ability to self-study/self-develop. Understanding of what a coder does/the clinical coder's role. Desirable Criteria
Experience of using NHS hospital administrative systems. Degree in science/healthcare. Medical terminology qualification. Skills & Abilities
Essential Criteria
Ability to work under pressure and meet deadlines. Ability to use own initiative to solve problems. Ability to prioritise own workload with conflicting demands. Excellent communication skills with the ability to work within a team. Excellent keyboard and IT skills. Proven attention to detail. Desirable Criteria
Experience with Home working.
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Clinical Coding is a highly skilled role. The post holder will attend the Standards Course and undergo specialised formal workshops and on-the-job training/mentoring, to build knowledge and competency levels to convert clinically generated text into a coded format, entering the codes on the Trusts' encoding system. They will work as part of a team responsible for the collation and translation of written diagnostic and procedural information from clinical documentation into internationally recognised codes, OPCS-4 & ICD-10, adhering to the rules agreed by the World Health Organisation. As a trainee, you will be expected to work towards the Accredited Clinical Coder qualification and study independently. Work is supervised by the Training Team & Coding Manager, supported by Accredited Clinical Coding Analysts until an agreed level of competence is reached. Main Responsibilities
Identify from the PAS system episodes to be coded. Extract relevant information regarding diagnosis/procedures/dates from the source document. Ensure from the episode details within the patient record, the finished consultant episode is coded according to the rules of ICD & OPCS, to provide consistent high-quality coding. On a daily basis complete the coding of those patients who have discharged episodes within the Trust PAS, inputting the code to the encoding system, in order to generate information for financial purposes (HRGs), clinical indicators, clinical governance, and local, national and international data. To assign, sequence and input all codes necessary to reflect the patient's total care, using ICD10 and OPCS4. To raise a problem report to identify documentation or episode data errors that impact the achievement of coding quality and completeness. To liaise with Auditors/Trainers to reach a firm decision as to the Diagnosis and Procedure to be coded when advice is required. Utilise the EPR and other relevant data/paper systems to retrieve data to assist in the coding of completed patient episodes. To ensure a high standard of coding quality and timeliness is maintained. To identify and locate the patient records or other relevant data to facilitate the coding of all uncoded episodes on a daily basis, ensuring complete coding of diagnostic and procedure codes to meet deadlines. Give support in the development of any new procedures and systems within the department. Maintain and update as necessary a personal copy of the relevant coding manuals, in accordance with national standards and guidance from the Training Manager & Coding Clinic. To receive training in and acquire skills in new coding schemes. Identify and report Data Quality issues to the Clinical Coding Manager. Work with those you support to develop a collaborative working partnership, which positively contributes to their overall efficiency and role performance. Person Specification
Education & Qualification
Essential Criteria
A level in science/biology. Knowledge of Anatomy & Physiology. Knowledge of Medical Terminology. Evidence of the ability to self-study/self-develop. Understanding of what a coder does/the clinical coder's role. Desirable Criteria
Experience of using NHS hospital administrative systems. Degree in science/healthcare. Medical terminology qualification. Skills & Abilities
Essential Criteria
Ability to work under pressure and meet deadlines. Ability to use own initiative to solve problems. Ability to prioritise own workload with conflicting demands. Excellent communication skills with the ability to work within a team. Excellent keyboard and IT skills. Proven attention to detail. Desirable Criteria
Experience with Home working.
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