Senior Clinical Coder

North Tees and Hartlepool NHS Foundation Trust; Tees Valley; On-site; GBP 30,000 - 36,000; Full time

Job summary

North Tees and Hartlepool NHS Foundation Trust seeks an experienced Clinical Coder to translate clinical information into ICD10 and OPCS4 codes accurately, ensuring complete data for financial revenue and mortality indicators. You will work with clinicians and coding assistants, meet deadlines, and contribute to service improvements.

The role requires Accredited Clinical Coding qualification, strong data analysis skills, and the ability to coordinate with multidisciplinary teams.

Qualifications

• GCSE level maths and English or equivalent.
• Accredited Clinical Coding qualification.
• Certificate in Anatomy & Physiology and Medical Terminology qualification.
• Basic computer skills (ECDL) required.

Responsibilities

• Work with clinicians to explain coding processes and standards.
• Liaise with wards to chase data.
• Ensure palliative care coding is used appropriately and monitored.
• Attend meetings to discuss coding and data quality.
• Improve communication between clinicians and coders.
• Coordinate timely collection of casenotes with coding team.
• Translate clinical information into ICD10 and OPCS4 codes accurately.
• Ensure submitted data is complete and accurate for financial revenue and mortality indicators.
• Contribute to improved accuracy of clinical coding for admitted care.
• Resolve coding queries and escalate when needed.
• Plan and prioritise workloads to meet targets and deadlines.
• Meet monthly departmental deadlines and plan workloads ahead.
• Spend most of day at computer with attention to detail.
• Support development of the Clinical Coding service.
• Assist in validating data quality with clinicians.

Skills

Interpersonal communication

Data extraction & analysis

Teamwork

Flexible work approach

Professional appearance

Education

GCSE Maths & English

Accredited Clinical Coding qualification

Certificate in Anatomy & Physiology

Medical Terminology Qualification

Basic computer skills (ECDL)

Tools

Patient Administration Systems

Encoders

Job description

Detailed job description and main 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 Trust's 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

Essential criteria

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

Experience

Essential criteria

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

Knowledge

Essential criteria

• 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

Essential criteria

• 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

Essential criteria

• Act as a mentor for less experienced coders

Communication

Essential criteria

• Excellent interpersonal and communication skills, written and verbal

Financial & Physical Resources

Essential criteria

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

Other

Essential criteria

• 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

Important

Once sufficient applications have been received this vacancy may close early.

Disclosure and Barring Checks (DBS)

It is the policy of North Tees and Hartlepool NHS Foundation Trust, that all successful candidates who are new to the Trust who require DBS clearance for the post they have been offered, are required to pay the cost for their DBS certificate. The method of payment for this is via salary deduction from your first month's pay on commencement with the Trust. The DBs check will be undertaken during the pre-employment check screening.

Qualifications

Please note the essential qualifications required for the post are outlined within the Person Specification. You are required to provide original evidence of the necessary qualifications for the post at interview should you be shortlisted. You will also be required to provide original copies as part of the pre-employment check screening.

New Starters - Probationary Period

For any new employees commencing employment with North Tees and Hartlepool NHS Foundation Trust, you will be subject to satisfactory completion of a 6 month probationary period. Please note that internal applications and individuals that are appointed to fixed term appointments of less than 6 months duration are exempt from the probationary period (unless you are an internal applicant currently part way through a probationary period or a bank member of staff).

Employment References

As part of our pre-employment screening process, all applicants are required to provide references covering their last three years employment history including any gaps. Applicants are requested to ensure e-mail addresses for all referees are included on their application form. Personal references are not acceptable.

Working Hours

If the hours advertised for the post are up to full time (37.5 hours per week), applications are still welcomed from individuals who may be seeking to work less than full-time hours and all requests will be considered in line with the post being appointed to for the successful applicant.

Equality, Diversity and Inclusion

Everything we do is shaped by our values: Respect, Support, and Collaborate.

At University Hospitals Tees we want our workspaces to be places where everyone feels welcome, valued and safe. We treat people with respect, and we celebrate the differences that make each of us unique.

We welcome applications from everyone, no matter your age, background, race, religion, disability, sex, sexual orientation, gender identity, family circumstances or beliefs.

We are here to support you throughout your application and at every stage of your career with us. We believe we work best when we collaborate, learn from each other and build teams that reflect the communities we serve.

Disability

We are a Disability Confident Lead employer. This means we give fair and full consideration to applicants and will offer reasonable adjustments during the recruitment process. If you need help with your application, or need the information in a different format, please contact our recruitment team and we will support you.

Right to Work in the UK

The Trust welcomes applications from all candidates who meet the criteria for the role. Please note that from January 2021, to work in the UK all candidates who are not UK or Republic of Ireland (RoI) nationals require sponsorship unless they have permission to work via another route. Non UK/RoI candidates wishing to apply can self-assess the likelihood of obtaining a Certificate of Sponsorship here: Work in the UK - GOV.UK (