Senior Clinical Coder

The post holder will be required to abstract, analyse and accurately code clinical information from patient records (paper and electronic) across all specialities using ICD-10 and OPCS-4 Classifications in accordance with National Standards and the Trust's Policy and Procedures guidelines. The role requires the successful candidate to produce consistent, accurate, complete and timely coded clinical data, for use by the Trust's Finance Department among others and to meet increasingly demanding deadlines whilst maintaining accurate coding at all times.

Our source documentation for coding is a mix of electronic and some paper documents, with an emphasis on moving towards a fully electronic patient record.

Possess the National Clinical Coding Qualification (NCCQ) UK or be working towards it

Have experience of using ICD-10 and OPCS-4 classifications (current version) in an acute hospital setting

Have extensive knowledge of medical terminology, anatomy and physiologyBe experienced in clinical coding for a wide range of specialties

Be proactive, flexible and supportive towards an electronic way of working as the Trust develops its electronic patient record

Have a strong team working ethos

To ensure accurate extraction of complex clinical details relating to diagnoses and operative procedures for each consultant episode from patient medical records

To engage and support the internal continuous audit process ensuring that a personal IG level 2 audit result is achieved and maintain

To assist in the daily supervision of trainee and less experienced clinical coding staff providing mentorship and cultivating a supportive learning environment

To interpret histology and radiology reports to ensure accuracy of the coding process

To undertake the coding of extracted information ensuring adherence to National Standards and local policies

To accurately enter the clinical codes onto the Trust information system PAS/Medicode

To identify insufficient/incorrect clinical data in source documentation and using own initiative to raise the query for resolution with other relevant departments

To share and assist other colleagues with personal coding experience and promote a learning environment at workplace

To organise daily workload efficiently so that personal coding targets are met, including allocated Consultant backlog list, supporting the coding team in achieving high standards of coding completeness and accuracy at agreed timescales

To take responsibility for self-development on a continuous basis by studying for the Auditor and/or Trainer qualification, if required by the Trust.

To participate in ongoing coding training and testing to meet National Standards and Trust requirements. This may require travelling to other organisations outside core working hours

To liaise with Clinicians and their support staff concerning interpretation of case note documentation affecting coding

To investigate and correct coded clinical data rejected or queried by recipient information systems

To communicate complex coding rules to clinical coding staff, medical, clinical and administrative staff and external agencies.

Implement agreed local policy directives and assist in the development of local coding policies which impact on the various service areas

Undertake/Participate in complex audits

To work across all specialities

We are committed to being an inclusive and diverse employer. We strive to employ people who reflect the communities we serve, and aim to create an inclusive culture where everyone can reach their full potential. Whatever your race, ethnicity, belief, generation, sexual orientation, gender or gender identity, disability or experience, you'll appreciate the opportunities we give you to work in an inclusive atmosphere. We welcome applications from people of diverse backgrounds, perspectives and experiences to build on the progress we've achieved to make our Trust diverse and the best place to work. We celebrate the diversity of thought, viewpoints and ideas that help us overcome challenges and embrace new possibilities. We have signed the Armed Forces Covenant Pledge and have a commitment to the Armed Forces Community.

If you are considering applying for a role, please be aware that as an NHS Employee you may have contact with vulnerable service users. We strongly encourage that all our staff are vaccinated against COVID-19 and are vaccinated annually against Flu, in order to protect the health and safety of our staff and patients. Your commitment will help us to put the safety and care of our patients first, as well as helping us to protect you and your colleagues.

Education and Training

Essential: - Accredited Clinical Coder qualification; - Coding Standards Course; - Recent Refresher workshop; - Evidence of ongoing professional development

Desirable: - Accredited Clinical Coding Auditor/Trainer qualification

Knowledge

Experience

Essential: - Recent Clinical coding experience in an Acute NHS Trust

Desirable: - Use of Patient Centre PAS; - Use of supportive systems such as Telepath; - Supervisory/leading team experience