Senior Clinical Coder

North Tees & Hartlepool NHS Foundation Trust; Tees Valley; Remote; GBP 32,000 - 39,000; Full time

Job summary

North Tees & Hartlepool NHS Foundation Trust is seeking aClinical Coder to abstract information from electronic records and translate it into ICD-10 and OPCS-4 codes across specialties. The role involves collaboration with clinicians to ensure accurate data and understanding of coding limits.

The post holder will mentor novice coders and support training while meeting national data standards. You may work across sites within University Hospitals Tees and participate in ongoing professional

Qualifications

• Educated to GCSE level or equivalent in Mathematics and English.
• Basic computer course, e.g. ECDL.
• Certificate in Anatomy & Physiology.
• Medical Terminology Qualification.

Responsibilities

• Abstract clinical information from patient records to translate into ICD-10 and OPCS-4 codes.
• Explain coding processes to clinicians and discuss complex information clearly.
• Attend meetings to discuss coding issues and data quality.
• Ensure coded data is complete and accurate and supports financial revenue and mortality indicators.
• Contact clinicians when documents are incomplete to enable accurate coding.
• Resolve coding queries and escalate when needed.
• Plan and prioritise workload to meet deadlines and inform line manager of hindrances.
• Meet monthly departmental deadlines and plan ahead for staff workloads.

Skills

Medical coding knowledge

Attention to detail

Data analysis

Mentoring juniors

Education

GCSE Maths & English

ECDL / Basic computer course

Certificate in Anatomy & Physiology

Medical Terminology Qualification

Job description

The post-holder will be responsible for the clinical coding of inpatient and day-case episodes across all specialties provided at North Tees and Hartlepool Hospitals.

The post involves liaising with clinicians and clinical teams on a regular basis to verify data recorded in patient case-notes and on electronic systems.

The post holder will contribute positively towards the development of the novice clinical coders, will act as mentor to and assist in the training of less experienced coders

Main duties of the job

Abstract clinical information from the electronic patient record to translate into diagnostic (ICD10) and operative (OPCS4) codes in a timely and accurate manner, applying national and international classification rules and conventions.

Work with clinicians to ensure they understand the coding process and its limitations, discuss complex clinical information and convey coding standards and requirements in language understandable by clinicians.

Attend meetings to discuss coding issues and data-quality as required.

Ensure coded data submitted is complete and accurate with full understanding of responsibility for generating the correct financial revenue for the Trust, and impact on Trust's mortality indicators.

5. Make decision to contact clinician if clinical document is incomplete or appears inaccurate meaning an accurate code assignment can not be made.

6. Ensure coding queries are resolved, escalating to the line manager where necessary.

7. Plan and prioritise own workload to meet performance and quality targets and, in a timely manner, advise the line manager of any hindrance to the achievement of these targets.

8. Ensure monthly departmental deadlines are met, in line with nationally mandated flex and freeze dates, including forward planning of workloads for self and less experienced team members.

About us

South Tees Hospitals NHS Foundation Trust and North Tees and Hartlepool NHS Foundation Trust have come together to form University Hospitals Tees. As a result, post holders may be required to work across sites within both organisations.

Across University Hospitals Tees, our ambition is to be the best place to work, ensuring we have the right staff in the right roles at the right time to deliver outstanding patient care and experience.

We are committed to supporting our staff through an inclusive and supportive working environment, offering health and wellbeing initiatives, staff benefits, and opportunities for personal and professional development.

We are committed to fostering an inclusive recruitment process and welcome applications from suitably qualified candidates, including those who first language is not English.

We support the 'Making Every Contact Count' approach to behaviour change in the promotion of health and wellbeing of individuals and communities.

Job responsibilities

Work with clinicians to ensure they understand the coding process and its limitations, discuss complex clinical information and convey coding standards and requirements in language understandable by clinicians;

Liaise with hospital wards and other departments as necessary to chase up outstanding source data;

Work with clinical teams to ensure that palliative care coding is used appropriately and monitored;

Attend meetings to discuss coding issues and data-quality as required;

Improve communication between clinicians and clinical coders regarding the coding process, by meeting and liaising with relevant clinicians on a regular basis agreeing and documenting outcomes;

Liaise closely with coding assistants to co-ordinate timely collection of casenotes in line with departmental deadlines;

Abstract clinical information from the electronic patient record to translate into diagnostic (ICD10) and operative (OPCS4) codes in a timely and accurate manner, applying national and international classification rules and conventions;

Ensure coded data submitted is complete and accurate with full understanding of responsibility for generating the correct financial revenue for the Trust, and impact on Trusts mortality indicators;

Contribute to improvements in accuracy and completeness of clinical coding for admitted care;

Make decision to contact clinician if clinical document is incomplete or appears inaccurate meaning an accurate code assignment can not be made;

Ensure coding queries are resolved, escalating to the line manager where necessary;

Plan and prioritise own workload to meet performance and quality targets and, in a timely manner, advise the line manager of any hindrance to the achievement of these targets;

Ensure monthly departmental deadlines are met, in line with nationally mandated flex and freeze dates, including forward planning of workloads for self and less experienced team members;

Spend majority of working day at computer, combining accurate keyboard skills with excellent attention to detail;

Maintain speed of work to produce expected level of coded data;

Assist in the continuing development and improvement of the Clinical Coding service in order that high quality-data can be collected and produced with minimum delay;

Support the Clinical Coding Managers and Training and Audit Team to establish a process to allow clinicians to validate and sign-off their own data quality and resolve their queries;

Keep abreast of all new national guidance in relation to clinical-coding practices and ensure own coding skills are kept up to date, widening and strengthening own skill-set across various clinical specialties;

Ensure all ICD/OPCS books are kept up to date with latest guidance;

Undertake appropriate training, as deemed necessary by the Training and Audit Manager and/or Clinical Coding Manager/Deputy Clinical Coding Manager;

Be aware of all statutory and local requirements regarding the disclosure/safe keeping of information e.g. the Data Protection Act, Caldicott etc.;

Support and act as mentor to less experienced coders, and assist with their development;

Participate in discussions relating to general coding problems and issues, for example, at departmental meetings;

Take responsibility for co-ordinating workload to ensure deadlines are met in the absence of Coding Manager/Deputy Coding Manager;

In periods of absence, cover the workload of other colleagues as required;

Provide motivational support to aid staff development.

Person Specification

Qualifications & Training

• Educated to GCSE level or equivalent in Mathematics and English
• Basic computer course, e.g. ECDL
• Certificate in Anatomy & Physiology
• Medical Terminology Qualification

Experience

• Attended refresher training and speciality workshops
• Ability to code a wide range of specialty areas
• Previous experience using encoders

Knowledge

• Thorough knowledge of medical terminology, anatomy and physiology
• Good understanding of uses of coded data
• Understanding of confidentiality in the workplace, Data Security and Caldicott

Skills & Attributes

• Ability to extract and analyse complex data from patient clinical records
• Ability to organise own workload and work to Trust deadlines
• Ability to work as part of a team

Management / Supervision

• Act as a mentor for less experienced coders

Communication

• Excellent interpersonal and communication skills, written and verbal

Financial & Physical Resources

• Able to spend extended periods sitting at workstation, concentrating on computer screen

Other

• Flexible approach to work and ability to prioritise workload
• Friendly and able to interact with colleagues
• Professional appearance
• Able to attend training at off-site venues

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.

£32,073 to £39,043 a yearpro rata, per annum

Contract

Permanent

Working pattern

Full-time,Flexible working,Home or remote working,Compressed hours