Trainee Clinical Coder / Clinical Coder

North Tees & Hartlepool NHS Foundation Trust; Tees Valley; Remote; GBP 26,000 - 27,000; Full time

Job summary

North Tees & Hartlepool NHS Foundation Trust is seeking a clinical coder to abstract information from case notes and electronic systems, translating it into ICD10 diagnoses and OPCS4 procedures. You will liaise with clinicians to verify data and ensure timely, accurate coding across inpatient and day-case episodes.

Flexibility to work across sites within University Hospitals Tees is possible. Training in NHS England Clinical Coding Standards will be provided, with a focus on continuous

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 to translate into ICD10 and OPCS4 codes accurately.
• Liaise with wards to view source documentation and collect discharge summaries.
• Improve accuracy and completeness of clinical coding for admitted care.
• Attend meetings to discuss coding issues and data quality as required.
• Prioritise own workload to meet performance and quality targets.

Skills

Attention to detail

Time management

Teamwork

Communication skills

Education

GCSE Maths and English

ECDL / Basic computer course

Certificate in Anatomy & Physiology

Medical terminology qualification

Tools

Encoders

Job description

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

About us

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.

Job 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

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

£25,760 to £27,476 a yearB4 and B5 available depending on training and experience

Contract

Permanent

Working pattern

Full-time,Flexible working,Home or remote working,Compressed hours