Trainee Clinical Coder / Clinical Coder

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

Job summary

NHS Jobs is seeking a Clinical Coder to translate clinical information into ICD-10 and OPCS-4 codes with accuracy and timeliness. The role involves liaising with hospital wards and other departments to access source documentation and ensure complete data for coding processes.

The post requires maintaining up-to-date coding skills, meeting quality targets, and contributing to departmental improvements in clinical coding services.

Qualifications

• Experience with clinical coding and disease classification.
• Ability to liaise with wards and departments to view source information.
• Proficiency with ICD-10/OPCS-4 and national guidance.
• Commitment to data quality and timely coding.

Responsibilities

• View source documents and coding references to assign ICD-10/OPCS-4 codes.
• Collaborate with wards, clinicians and departments to obtain needed information.
• Attend departmental meetings and assist in coding discussions and data-quality improvements.
• Prioritise workload to meet performance and quality targets and escalate issues as needed.

Skills

Clinical coding

Liaison with clinicians

Data quality

Workload management

Tools

ICD-10 coding

OPCS-4 coding

Job description

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.

£25,760 - £27,476 B4 and B5 available depending on training and experience