Lead Clinical Coder

NHS; Norwich; Hybrid; GBP 35,000 - 45,000; Full time

Job summary

A leading healthcare provider is seeking an experienced Clinical Coder to ensure high-quality coding data. The role involves coding complex clinical information, collaborating with clinicians, and maintaining coding standards in compliance with NHS regulations. The ideal candidate will have strong analytical skills and the National Clinical Coding Qualification.

Benefits

25 days annual leave plus Bank Holidays

Private Healthcare

Company Pension Scheme

Life Assurance

Blue Light Card

Refer a Friend Scheme

Wagestream

Reward Gateway

Cycle to Work Scheme

Smart Tech

Qualifications

• Extensive experience as a Clinical Coder required.
• Full understanding of ICD10 and OPCS.
• Ability to work independently and manage workload.

Responsibilities

• Code medical records accurately using ICD-10 and OPCS-4.
• Collaborate with clinical staff regarding diagnoses.
• Participate in audits and quality improvement initiatives.

Skills

Attention to detail

Analytical skills

Communication

Education

National Clinical Coding Qualification (ACC)

Tools

SystemOne

PatientSource

Job description

Remote with some travel to Norwich and London

We are seeking a meticulous and experienced Clinical Coder able to workindependently, to join us. The successful candidate will be responsible foraccurately coding medical records using ICD-10 and OPCS-4 classifications,ensuring compliance and hold the National Clinical Coding Qualification (ACC)

Main duties of the job

• Analysing and coding patient records using ICD-10 and OPCS-4 classifications.
• Ensuring accuracy and completeness of coded data.
• Collaborating with clinical staff to clarify diagnoses and procedures.
• Maintain up-to-date knowledge of coding standards and practices.
• Participating in audits and quality improvement initiatives.
• Project work to combine systems which is taking place/due to take place.
• Working across different sites.

About us

We're an independent healthcare provider, with established roots in muscular-skeletal health and diagnostics, founded by expert NHS clinicians who recognised a way to improve things.

Our approach means that whether it's speed, flexibility, efficiency or quality, every aspect has been carefully considered to surpass expectations. This is why we've been a trusted partner of the NHS for over ten years, and the provider of choice for countless private patients.

We work with integrity. When it comes to collaboratively delivering care, relationships are key. Whether we're interacting with each other, our partners or our patients, we're always open and honest. Every key decision is based on clear process and informed by evidence.

We act with empathy. Everyone who is here, is here because they care about people. We always try and put ourselves in the shoes of whomever we're interacting with and treat people with compassion and consideration.

We inspire with passion. It's hard work, but we absolutely love what we do. There's no room for a half-hearted approach to healthcare, it requires dedication, and that's what everyone here has. A Healthshare employee is enthusiastic, with a verve and panache that inspires others around them.

• 25 days annual leave (plus Bank Holidays) and option to buy/sell
• Private Healthcare (Benenden)
• Company Pension Scheme
• Life Assurance
• Blue Light Card
• Refer a Friend Scheme
• Wagestream
• Reward Gateway
• Cycle to Work Scheme
• Smart Tech
• EV Car Scheme

Job responsibilities

Job Purpose

• The Post holderwill be responsible for ensuring high-quality clinical coding data
• They will berequired to collect, collate and code clinical; information, often highlycomplex in nature, covering a wide range of specialties
• To ensure thequality and depth of coding adhere to the national clinical coding standardsset out by NHS England to provide consistently recorded data to well definedstandards
• Clinical Codingis continuously monitored and improved, to provide complete, timely usefulquality data
• The post holderskey responsibility is to abstract complex clinical information from thepatients health record on discharge and translate the medical terminology intoalphanumerical codes using the International Classification of Diseases (ICD10) for diagnoses, and the OPCS Classification of interventions and proceduresin compliance with national clinical coding standards and guidelines
• To liaise withother departments including clinicians, medical secretaries, nursing staff,medical records team, and ward clerk to promote confidence and awareness inclinical coded data
• To action codingqueries as raised by members of the clinical coding team, sharing expertise,and assisting in the interpretation of complex information ensuring nationalstandards are adhered

Key roles and responsibilities

• To explain how to maximise the organisations income and dataquality by sharing what clinical information is required on the patientsmedical record
• Adhere to the rules and conventions of ICD-10 and OPCS and takeresponsibility for updating your own references manuals and classificationswhen changes have been issued
• To input coded information into thehospital PAS computer system, paying particular attention to accuracy,timeliness and confidentiality
• Liaise regularly with internal andexternal key stake holders to ensure high quality coded clinical data
• Ensure allqueries raised by staff are resolved promptly and effectively, or whereappropriate are referred to the Clinical Coding coder.
• Accompany wherenecessary the Coding Auditor (external) to discuss coding issues relevant toareas of expertise
• The post holderwill identify opportunities for improvement related to clinical coding. Aproactive approach to service development is encouraged
• Ability to keepteam members informed of progress, changes, and deadlines, sharing knowledgeand experiences with the whole team
• Adaptable tochanging priorities, such as maintenance of on-going projects while dealingwith urgent ad-hoc work
• Working accordingto the individual clinical coding audits, where you are expected to meet theminimum data standards outlined in the clinical coding audit policy
• Takeresponsibility for locating missing histology results at the time of coding andupdating the clinical data, in accordance with those results in time for theSUS submission date
• Be responsiblefor updating personal coding classifications following changes to standards,published by NHS England Terminology Classification Service
• Use own judgementto translate cases and assign the relevant codes where information isnt alwaysclear
• Report complexcoding issues as a directed for verification and/or send to the NHS Englandclassification help desk. Share all responses with relevant staff
• Work in partnership with the development of newservice and procedure mobilization, modelling the financial returns fromprocedure coding to support business case development

Key Working Relationships

• Regular verbal, written and electronic communication with clinicalteams and non-clinical teams to ensure timely availability of case notes andclinical information for coding
• At times required to relay highly complex coding information toother colleagues and or other staff groups outside the department includinglead clinicians
• Works effectively as an individual and as part of a team
• To escalate unresolved clinical coding queries and operationalissues to the IT and data team
• To actively lead and participate in staff rotation
• Communicate complex coding rules and standards and provide support tocolleagues where required
• Effectively work alongside Finance and Information Teamscalculating tariffs and providing clinical codes and HRGs when required
• Liaiseregularly with clinicians regarding complex clinical documentation making jointdecisions on correct codes to use to accurately reflect clinical activity
• Is ableto work effectively across teams and specialities within the department.
• Self-management and an ability to achieve targets as defined by the executiveteam
• Excellent communication skills, with an ability to relay complex clinicalcoding information to operational staff and clinicians.
• Be confident in the use of clinical IT systems andinterrogating electronic patient records to abstract information for clinicalcoding

Person Specification

Qualifications

• National Clinical Coding Qualification (ACC)

Experience

• Proven extensive experience as a Clinical Coder with the ability to use SystemOne and PatientSource.

Knowledge and skills

• Full understanding of ICD10, OPCS and the impact of HRGs.
• Detailed knowledge of medical terminology, human anatomy and coding procedures.
• Excellent attention to detail and analytical skills.
• Strong communication and interpersonal skills.
• Ability to work independently and autonomously, with no supervision.
• Take ownership of own workload, priorities, and risks.

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.