Trainee Clinical Coder / Clinical Coder

NHS Trust; Tees Valley; On-site; GBP 26,000 - 27,000; Full time

Job summary

North Tees and Hartlepool NHS Foundation Trust is seeking a Clinical Coding Officer responsible for coding inpatient and day-case episodes across multiple specialties. You will translate case-notes into ICD-10 and OPCS-4 codes, liaising with clinical teams to ensure accuracy and timely data submission.

The role requires training in NHS coding standards, attention to detail and the ability to work across sites within the Trusts. A probationary period and DBS considerations apply.

Qualifications

• Educated to GCSE level or equivalent, including Maths and English
• Basic computer course, e.g. ECDL
• Certificate in Anatomy & Physiology
• Medical terminology qualification

Responsibilities

• Abstract clinical information from the case-note/electronic system to translate this into diagnostic (ICD10) and operative (OPCS4) codes in a timely and accurate manner, applying national and international classification rules and conventions
• Liaise with hospital wards and other departments as necessary to view information in source documentation (case notes), required to complete coding; to collect source document sheets (e.g. discharge summaries); to take reasonable steps to chase up outstanding source data. Source documents will increasingly include electronic records
• Contribute to improvements in accuracy and completeness of clinical coding for admitted care
• Attend meetings to discuss coding issues and data-quality as required
• Work and improve communication between clinicians and clinical coders to ensure they understand of coding process and its limitations, by meeting and liaising with relevant clinicians on a regular basis
• Highlight issues relating to administrative coding discrepancies such as clinician or method of admission etc.
• Ensure coding queries are resolved, escalating to the Manager / Deputy Manager where necessary
• Participate in discussions relating to general coding problems and issues, for example, at departmental meetings
• Plan and prioritise own workload to meet performance and quality targets and, in a timely manner, advise the Manager / Deputy Manager of any hindrance to the achievement of these targets
• 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
• Advise the Manager / Deputy Manager on the standards of information provided for clinical coding, particularly if this becomes unacceptable; to evaluate and discuss with the manager any problems that arise, and assist in the implementation of any changes required
• In periods of absence, cover the workload of other colleagues as required
• 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
• 14. Undertake appropriate training, as deemed necessary by the Training and Audit Manager and/or 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.

Job description

Find out about the current vacancies available at the Trust and take the next step in your career with us.

Site University Hospital of North Tees Town Stockton-on-Tees Salary £25,760 - £27,476 B4 and B5 available depending on training and experience Salary period Yearly Closing 11/11/2026 23:59

Job overview

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.

This post may close early if sufficient amount of applications are reached.

Main duties of the job

Undertake office based clinical coding training and NHS England Clinical Coding Standards Course t achieve proficiency in clinical coding.

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

Working for our organisation

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.

Detailed job description and main responsibilities

Abstract clinical information from the case-note/electronic system to translate this into diagnostic (ICD10) and operative (OPCS4) codes in a timely and accurate manner, applying national and international classification rules and conventions;

Liaise with hospital wards and other departments as necessary to view information in source documentation (case notes), required to complete coding; to collect source document sheets (e.g. discharge summaries); to take reasonable steps to chase up outstanding source data. Source documents will increasingly include electronic records;

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

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

Work and improve communication between clinicians and clinical coders to ensure they understand of coding process and its limitations, by meeting and liaising with relevant clinicians on a regular basis;

Highlight issues relating to administrative coding discrepancies such as clinician or method of admission etc.;

Ensure coding queries are resolved, escalating to the Manager / Deputy Manager where necessary;

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

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

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;

Advise the Manager / Deputy Manager on the standards of information provided for clinical coding, particularly if this becomes unacceptable; to evaluate and discuss with the manager any problems that arise, and assist in the implementation of any changes required;

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

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;

14. Undertake appropriate training, as deemed necessary by the Training and Audit Manager and/or 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.

Person specification

Qualifications & Training

• Educated to GCSE level or equivalent, including Maths and English
• Basic computer course, e.g. ECDL
• Certificate in Anatomy & Physiology
• Medical terminology qualification

Experience

• Understanding of a health record / previous health records experience
• Experience of administrative processes
• Ability to work as part of a team
• Previous experience using encoders

Knowledge

• Understanding of uses of clinical coded data in NHS
• Understanding of confidentiality in the workplace, Data Security and Caldicott
• Knowledge of medical terminology, anatomy and physiology

Skills & Attributes

• Ability to organise own workload and work to Trust deadlines
• Ability to work as part of a team
• Excellent attention to detail
• Keen to learn and enthusiastic to progress

Communication

• Excellent interpersonal and communication skills, written and verbal

Other

• Flexible approach to work and ability to prioritise workload
• Friendly and able to interact with colleagues
• Professional appearance

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 ( www.gov.uk )

Please provide full and accurate details of your current immigration status on the application form. Your current immigration status will not be considered as part of the shortlisting or interview process.

Please note that not everyone needs a ‘Skilled Worker’ visa. If you are applying for health or social care, you may be eligible to apply for the Health and Care Worker visa instead.

As a supporter of the Armed Forces and an employer of Reservists, North Tees and Hartlepool NHS Foundation Trust are proud to be a signatory of the Armed Forces Covenant, which is a promise by the nation to ensure that those who serve or who have served in the UK Armed Forces (and their families) are treated fairly.

We recognise that reservists and veterans bring a variety of transferable skills and qualities to our workplace, developed through their military careers. Our commitment to supporting the Armed Forces Community has been recognised through the Armed Forces Covenant as a Silver Employer.

Further Important Information

Please check your email on a regular basis for updates on your application. If you are shortlisted for interview, you will be invited to email via this method.

Please ensure you read the ‘Guidance Notes for Applicants’ document attached to this advert before completing and submitting your application.

Unfortunately, we are unable to respond to all applicants and those who are not contacted within six weeks of the closing date should assume that their application has been unsuccessful.

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