Trainee Clinical Coder / Clinical Coder

North Tees and Hartlepool NHS Foundation Trust; Tees Valley; On-site; GBP 25,000 - 35,000; Full time

Job summary

North Tees and Hartlepool NHS Foundation Trust is seeking an efficient Clinical Coding Administrator to translate clinical notes into standardized codes. You will liaise with wards and reviewers, ensuring accurate data capture and timely processing within the NHS framework.

The role emphasizes collaboration with clinicians, adherence to data protection standards, and participation in ongoing development of coding practices to maintain high-quality data.

Qualifications

• Understanding of a health record / previous health records experience.
• Experience of administrative processes.
• Ability to work as part of a team.
• Understanding of uses of clinical coded data in NHS.
• Confidentiality, Data Security and Caldicott considerations.
• Knowledge of medical terminology (Desirable).

Responsibilities

• Abstract clinical information from case notes to translate into ICD10/OPCS4 codes.
• Liaise with hospital wards to access source records and collect discharge summaries.
• Improve accuracy and completeness of clinical coding for admitted care.
• Attend meetings to discuss coding issues and data quality.
• Communicate with clinicians to explain coding process and its limitations.
• Resolve coding queries and escalate as needed to management.
• Plan and prioritise workload to meet performance targets.
• Support development of the Clinical Coding Service.
• Keep up to date with national guidance on coding practices.

Skills

Organisational skills

Teamwork

Attention to detail

Communication skills

Education

GCSE Maths and English

Tools

Patient Administration Systems

Encoders

Job description

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

Essential criteria

• Educated to GCSE level or equivalent, including Maths and English

Desirable criteria

• Basic computer course, e.g. ECDL
• Certificate in Anatomy & Physiology
• Medical terminology qualification

Experience

Essential criteria

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

Desirable criteria

• Previous experience using Patient Administration Systems
• Previous experience using encoders

Knowledge

Essential criteria

• Understanding of uses of clinical coded data in NHS
• Understanding of confidentiality in the workplace, Data Security and Caldicott

Desirable criteria

• Knowledge of medical terminology, anatomy and physiology

Skills & Attributes

Essential criteria

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

Desirable criteria

• Keen to learn and enthusiastic to progress

Communication

Essential criteria

• Excellent interpersonal and communication skills, written and verbal

Other

Essential criteria

• 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 (