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A leading healthcare provider is seeking a Clinical Coder to assign clinical codes to diagnoses and procedures. This role involves working closely with clinicians to ensure accurate coding while maintaining patient confidentiality. Applicants should possess essential qualifications such as GCSEs in English and Maths, along with accredited clinical coding qualification. This position offers an opportunity to contribute to high-quality healthcare services.
Mid and South Essex NHS Foundation Trust is the only acute hospital provider in the Mid and South Essex Integrated Care System (ICS), which is a system of health and care partners working together for our local population.
Within Mid and South Essex there are 149 GP practices, operating from over 200 sites, forming 27 Primary Care Networks and one Ambulance Trust. There are also three main community and mental health service providers who work together through a community collaborative.
We collaborate with other valuable partners, including three Healthwatch organisations, nine voluntary and community sector organisations and three top tier local authorities, with seven district, borough and city councils, as well as our local universities.
Job overview
JOB SUMMARY
The post-holder is responsible for assigning correct clinical codes to Diagnoses and Operative Procedures against nationally agreed standards, in order to produce reliable clinical information for commissioning, reimbursement (based on HRG assignment), audit, research and performance indicator production.
The post-holder will work with clinicians on a regular basis to help validate their coding in order to produce more accurate coding to facilitate the Payment by Results process.
(We are not able to offer sponsorship on any bank vacancies at MSE so all applicants must possess unrestricted right to work in the UK)
Main duties of the job
Analytical and Planning
To abstract and analyse complex clinical information from patient records and translate this into a coded format in line with National Standards.
To code the specified number of episodes on a daily basis.
To be responsible on a day-to-day basis for the abstraction and analysis of complex and sensitive information from health records.
This information often includes exposure to highly disturbing and upsetting details or photographs.
To have a high level of knowledge of Medical Terminology and Anatomy and Physiology.
Working for our organisation
Mid and South Essex NHS Foundation Trust is now one of the largest Trust in the country, serving a population of 1.2 million people. Our newly formed Trust, comprising acute hospital sites at Broomfield in Chelmsford, Basildon, and Southend, is determined to provide the best health services for its local population. We are a well-led, high-performing, and innovative organisation working in the best interests of the people we serve.
With a workforce of approximately 15,000 staff, we can now do more and go further in delivering health services to our local communities.
Our ambition is to deliver excellent local and specialist services, to improve the health and wellbeing of our patients, and provide a vibrant place for staff to develop, innovate and build careers.
Detailed job description and main responsibilities
1. Communication
To attend seminars and training courses in order to receive and interpret clinical coding updates and effectively communicate these to all necessary staff.
Take part in departmental team meetings to discuss and agree local policy and coding convention variations as required, without contravening national standards to ensure consistency of coding across the Trust.
To act as lead contact with designated specialties and communicate complex issues with clinicians on coding queries relating to diagnoses and operative procedures in order to ensure accuracy and consistency of information.
Where applicable, attend clinical and management meetings to discuss complex coding rules and guidelines and answer questions with regard to coding, thus raising awareness of the importance of clinical coding.
2. Analytical and Planning
To abstract and analyse complex clinical information from patient records and translate this into a coded format in line with National Standards.
To code the specified number of episodes on a daily basis.
To be responsible on a day-to-day basis for the abstraction and analysis of complex and sensitive information from health records. This information often includes exposure to highly disturbing and upsetting details or photographs.
To have a high level of knowledge of Medical Terminology and Anatomy and Physiology.
3. Policy and Service Development
To assist in the organisation of the day-to-day running of the office and use initiative to prioritise own workload to ensure that coding is carried out in an accurate, timely and complete manner.
4. Financial and Physical Resources
Be aware of any problems in the office and report to appropriate manager or works department for remedial action.
Be aware of health and safety and incidents procedure.
Monitors stationery supplies as are necessary to complete tasks.
5. Staff Management
Act as mentor and assist in the education of less experienced coders.
To develop, in conjunction with the Clinical Coding Site Manager and Clinical Coding Deputy Site Manager, coding standards, and maintain on-going monitoring and audit procedures to ensure that coding is timely, complete, accurate and of a consistent high quality to meet the needs of the Trust.
6. Information Resources
Using national and international rules/conventions governing the use of the statistical classifications (ICD10 and OPCS4) as laid down by the World Health Organisation and connecting for health and comprehensive knowledge of anatomy, physiology and medical terminology, translate all diagnostic and procedural information relating to a patients care in hospital, including patient co-morbidities into coded data.
The post holder will work as part of a team of experienced trained and trainee staff and the job will involve rotation between duties working on all specialties.
Locate source documents, read and analyse histology and cytology reports. Access information from help sources i.e. internet coding websites, and other online medical information sites.
Manage and resolve enquiries relating to complex clinical information from all parts of the hospital received in the Department.
Ensure patient records are processed in the correct manner and paper records are tracked to appropriate destinations using the computer tracking system.
To ensure computer and paper records are passed for remedial action or processed in the correct manner.
Knowledge of specialised computer coding software, coding procedures and conventions.
Ensure compliance with relevant legislation and Trust policy in areas of Health and Safety, Confidentiality and Data Protection.
Person specification
Qualifications
Essential criteria