Trainee Clinical Coder

Bolton Nhs Foundation Trust; Bolton; Hybrid; GBP 21,000 - 26,000; Full time

Job summary

Bolton NHS Foundation Trust invites applications for a Trainee Clinical Coder to join our Clinical Coding team. This role offers a structured training pathway combining national and local training, supervised practice and progression toward the Clinical Coding Standards Course.

You will learn to abstract and translate clinical documentation into ICD-10 and OPCS-4 codes under supervision, retrieving notes and using EPR, PAS and ICE.

Qualifications

• No prior coding experience required.
• Five GCSEs at grade 4/C or above (including Maths, English and Biology or Combined Science).
• Accurate computer and data-entry skills; strong eye for detail; commitment to study toward a professional qualification.

Responsibilities

• Undertake supervised clinical coding of inpatient and day-case activity in trainee specialties.
• Abstract, analyse and translate clinical information using ICD-10 and OPCS-4 with guidance.
• Retrieve missing notes, reports and test results as directed.
• Escalate unclear or incomplete documentation to supervising staff.
• Submit coded work for checking and validation.
• Use EPR, PAS and ICE at trainee level; report technical issues to seniors.
• Handle patient data securely in line with GDPR and governance policies.
• Follow departmental training plan and work toward accreditation.
• Maintain clear working notes and development logs.

Skills

GCSEs

Data entry

Attention to detail

Education

GCSEs (5 including Maths English Biology)

Tools

EPR

PAS

ICE

Job description

An exciting opportunity has arisen to join our Clinical Coding team as a Trainee Clinical Coder. This is a post for someone who wants to build a career translating clinical information into the coded data that underpins patient care, service planning and Trust income. You will follow a structured training programme combining national and local training, supervised practice and competency-based progression, working towards passing the Clinical Coding Standards Course. You will learn to abstract, analyse and translate clinical documentation into ICD-10 and OPCS-4 codes, working within designated training specialties under close supervision from other coders and the training leads., Working under close supervision, you will:

• Undertake supervised clinical coding of inpatient and day-case activity within designated trainee specialties, following national standards and local instructions.
• Learn to abstract, analyse and translate clinical information from patient documentation, applying ICD-10, OPCS-4, sequencing rules and national conventions with guidance. This involves 25 days classroom based training.
• Retrieve missing clinical information such as notes, reports and test results as directed.
• Escalate all unclear, incomplete or ambiguous documentation, and any coding query beyond your current competence, to supervising staff.
• Submit all coded work for checking and validation, responding positively to feedback and acting on any errors identified.
• Use EPR, PAS, ICE and other systems safely at trainee level, reporting technical issues to senior colleagues.
• Handle patient information securely and confidentially in line with GDPR, Caldicott, DSPT and Trust information governance policies.Follow the departmental training plan, attending supervised coding sessions, team meetings and learning activities, and working through competency requirements towards becoming an accredited clinical coder.
• Maintain clear working notes, coding examples and development logs for review.

Please note that all coded work is checked until you are formally signed off in a specialty; this post does not code independently.
No previous coding experience is needed. We're looking for someone with 5 GCSEs at grade 4/C or above (including Maths, English and Biology or Combined Science), accurate computer and data-entry skills, a strong eye for detail, and the commitment to study towards a professional qualification. Experience in an NHS or healthcare setting is welcome but not essential. You'll need to attend the department full-time until assessed as competent to work independently, after which hybrid working is available. Initially, you will also be required to assist with the location of case notes for coding and other clerical work.
We have a long and proud history of caring for generations of local people and can trace our roots all the way back to 1814 with the first hospital in Bolton - the Bolton Dispensary in the town centre. Bolton NHS Foundation Trust was formed in 2008 and, in 2011, we became an integrated provider with community health services joining the trust. Covering a catchment area that also incorporates parts of Bury, Wigan and Salford, we deliver hospital and community based services from the Royal Bolton Hospital in Farnworth and from 20 health centres across Bolton, to a catchment population of 310,000+ people. The Royal Bolton Hospital is a major hub within Greater Manchester for women's and children's services and is the busiest single ambulance-receiving site in Greater Manchester. We're structured in four clinical divisions - Community Services, Families and Diagnostics, Medicine, and Surgery and are led by a Board of Directors. As an NHS Foundation Trust we're accountable to our members and have a Council of Governors to represent the views of patients, public, staff and partners. Buildings, names and models of care have changed over the centuries, but one thing has remained constant and is prevalent among our 6,718 staff members: the enduring commitment to providing the best health and care for the people of Bolton.