Senior Clinical Coder

Merseywestlancs; Knowsley; On-site; GBP 25,000 - 35,000; Full time

Job summary

Mersey and West Lancashire Teaching Hospitals NHS Trust is seeking an experienced Clinical Coder to join our professional Coding Department. The role offers a flexible working pattern including potential home working and a comprehensive training plan to maintain high coding quality across specialties.

You will apply ICD-10 and OPCS-4 coding rules, ensuring timely, accurate data while supporting ongoing development and learning within a collaborative team.

Qualifications

• Must be able to code accurately using ICD-10 and OPCS-4.
• Solid command of medical terminology, anatomy and physiology.

Responsibilities

• Ensure accurate clinical coding within prescribed timescales.
• Abstract info from health records and translate to ICD-10/OPCS-4.
• Maintain high data quality and adhere to standards and guidelines.
• Communicate with clinicians and staff to ensure data quality.
• Promote coding policies and support continuous training.

Skills

ICD-10 & OPCS-4 coding

Medical terminology

Attention to detail

Teamwork

Education

GCSEs (A-C) or equivalent

Clinical Coding Standards Course (UK)

Job description

Job Overview

We have a vacancy for an experienced Clinical Coder to join our highly professional team.

You will benefit from a detailed personalised training plan to ensure that you attain and maintain high standards of clinical coding quality. You will gain skills and experience across a wide range of specialties.

Our Clinical Coding Department is forward‑thinking and dedicated to personal staff development. We offer the possibility of working from home (to be discussed at interview) and family‑friendly, flexible working hours. In addition you must have clinical coding experience in a number of specialties.

You will demonstrate current correct application of the rules and conventions of clinical coding, supplemented by a solid understanding of medical terminology, clinical terms and anatomy and physiology.

Please note, interview will include an assessment. Interviews will be held to be confirmed.

Main Duties

You should be enthusiastic about the challenges of a busy, constantly changing environment. You must remain calm under pressure and work as part of a dynamic team. You should have proven ability to prioritise, plan and organise work on a daily basis. The post holder will ensure that patient activity data is fully and accurately coded within prescribed timescales, whilst adhering to national and local standards and realistic productivity targets.

In return, you can expect full support to enhance and develop your clinical coding skills. Ongoing training will be delivered by our training team. You can also benefit from a supportive team structure and opportunities to develop your career.

Key Duties

• Ensure accuracy and completeness of clinical coding which underpins the Payment by Results framework and national clinical coding requirements.
• Abstraction of clinical information from the health record and translation of that medical terminology using ICD‑10 and OPCS‑4 into a form that can be tabulated, aggregated and sorted for statistical analysis and to support the Payment by Results agenda applying national rules and conventions to agreed standards.
• Demonstrate effective organisational and time‑management skills with the ability to work independently and as part of a team. Be highly motivated and lead by example to motivate other team members.
• Carry out clinical coding to the highest level of specificity using the three dimensions of coding accuracy, thus giving complete and accurate data of high quality that is consistently recorded.
• Routinely extract pathology, histology and radiology information and use it for more accurate clinical coding in a timely fashion in accordance with coding deadlines.
• Work on own initiative in collecting information by whatever means required, including entering very specific areas of the Trust. Exercise diplomacy and confidentiality in pursuit of collecting this data.
• Work towards gaining experience in other coding areas that fall outside the standard processes such as Burns & Plastics, Obstetrics, Gynaecology and Oncology.
• Act as first‑line enquiry for requests for information either in person, by e‑mail or via telephone.
• Promote and implement clinical coding policies, procedures and national guidelines.
• Assist the Coding Delivery Team Manager to identify complex issues in clinical information contained in the record and electronic systems that contradict coding guidelines.
• Assist the Coding Manager to identify discrepancies in computer and hard‑copy information, ensuring accurate data quality.
• Monitor data quality and coding standards in line with local and national guidelines. Report complex coding issues for verification or send to the Clinical Coding Classification Service help desk, sharing all responses with relevant staff.
• Remove or amend clinical codes to Finished Consultant Episodes (FCEs) as directed by the manager or Information Department. Re‑input clinical codes as necessary.
• Communicate effectively with clinicians, managers, information, finance and other staff members to ensure high quality of coded data. Provide complex coding advice and information to colleagues within the NHS.
• Liaise with clinicians, researchers and healthcare professionals on a regular basis to provide and help with information as required, explaining the requirements of the classifications and how to implement them.
• Attend meetings when required to promote coding, the rules and conventions that surround it, and raise awareness of the importance of accurate data.
• Promote thorough knowledge and understanding of the rules and conventions surrounding ICD‑10 and OPCS‑4 to all levels of staff within the Trust.
• Further develop a team approach within the service, leading by example in all areas of clinical coding.
• Remain flexible in the duties performed and be prepared to carry out similar duties not specifically listed, which may be cross‑site.

Clinical & Professional Responsibilities

• Take every responsible opportunity to maintain and improve professional knowledge and competence.
• Maintain an excellent knowledge of medical terminology, anatomy and physiology.
• Attend regular relevant training and workshop sessions.
• Maintain a high level of competency in the recording of clinical codes and completion of assessments as required to measure accuracy and quality of coded data.
• Keep up to date with the regular updates and amendments to ICD‑10 and OPCS.

Administrative Responsibilities

• Validate hospital activity details on the PAS system against casenote information. Report any discrepancies to the Data Quality Team and highlight areas of concern documented in the case notes.

Teaching & Training Responsibilities

• Continue to update clinical coding skills by attending mandatory specialty workshops and refresher courses.
• Attend local mandatory training in line with Trust policies.

Person Specification

Skills

• Ability to work on own initiative and as part of a team.
• Effective interpersonal skills.
• Excellent concentration with attention to detail.
• Flexible approach to work.

Knowledge

• Experience working in an office environment.
• Planning, organising workload to meet deadlines.
• Transferring coding skills and knowledge to others.
• Experience in coding multiple specialties using ICD‑10 and OPCS classifications.
• Firm grounding in medical terminology, anatomy and physiology.
• Excellent knowledge and understanding of coding rules and conventions.
• Experience working with clinicians and senior clinical staff.
• Experience mentoring junior team members.
• Knowledge of Information Governance, Data Protection, legislation, Caldicott and other relevant guidance.
• Knowledge of Payment by Results framework.
• Knowledge of SNOMED CT.

Qualifications

• GCSEs (A‑C) or equivalent qualification and/or equivalent experience.
• Clinical Coding Standards Course (UK) or equivalent qualification.

Additional Requirements

• Ability to travel across the various Trust sites.

Equality, Diversity and Inclusion

We actively cultivate a professional environment of fairness, equality, dignity and respect for all individuals. We welcome individuals from all backgrounds and value the unique skills, perspectives and experience they bring. Diversity enhances our collective strength, fostering innovation and excellence within our workforce. We welcome all applications irrespective of race, disability, gender, sexual orientation, religion or belief, age, gender identity, marriage or civil partnership, pregnancy or maternity and, in particular, those from under‑represented groups.

As a Disability Confident Leader, we commit to offering an interview to all disabled applicants who meet the minimum criteria for the job.

We also commit to offering an interview to all armed forces veterans who meet the minimum criteria.

Immigration and Visa

Following the recent update on UK immigration policy for Health and Care Visa or Skilled Worker Visa holders, please check your eligibility before applying as we may be unable to provide sponsorship.

Disclosure and Barring Service Check

If this post is subject to the Rehabilitation of Offenders Act, a DBS check will be requested. Applicants may need to pay for the DBS check; costs are deducted from salary following appointment. Enrol for the DBS Update Service if not already done.

Flexible Working

All employees have the right to request flexible working from day one of employment. There is no limit on the number of requests they can make. Requests will be considered, regardless of the reason. We encourage discussion of flexible working options at interview.

Working for Our Organisation

Mersey and West Lancashire Teaching Hospitals NHS Trust serves a population of over 600,000 with a workforce of over 9,000 staff across 21 sites. We provide acute, primary, community and specialist regional services. Our Trust has been rated Outstanding by CQC, is a Top 100 NHS workplace and has earned national preceptorship accreditation.

Additional Information

Before applying, review our Trust values and behaviours: We are KIND, We are OPEN, We are INCLUSIVE.

An applicant guide and supporting documents are available on the application portal.