ACC Senior Clinical Coder

Job overview

Are you passionate about healthcare, data quality and making a real impact behind the scenes? We are looking for an Accredited Clinical Coder, to play a vital role in transforming complex patient information into accurate, nationally recognised clinical data that supports patient care, NHS funding, service planning and performance reporting.

In this rewarding and intellectually stimulating role, you will review and interpret detailed clinical records from patient case notes and electronic health systems, applying your expert knowledge of ICD-10 and OPCS-4 classifications to accurately assign diagnostic and procedure codes in line with national coding standards. Every record presents a unique challenge, requiring analytical thinking, attention to detail and the ability to interpret complex clinical information to make informed coding decisions.

Working closely with clinicians and multidisciplinary teams, you will ensure that each patient's hospital journey is accurately and comprehensively represented. You will use your specialist expertise to explain coding decisions, provide advice on complex coding scenarios and contribute to maintaining the highest standards of data quality across the Trust.

The successful candidate will be an Accredited Clinical Coder (ACC), having achieved the National Clinical Coding Qualification, and will be committed to maintaining professional standards within this highly respected and valued profession.

Main duties of the job

Clinical Coders are essential to the NHS, providing the data that underpins healthcare planning, clinical research, national reporting and the allocation of funding. This role offers the opportunity to make a meaningful contribution to the delivery and future development of healthcare services while continually developing your specialist knowledge and expertise.

To accurately extract, analyse and translate clinical information from clinical records into nationally recognised diagnosis (ICD 10) and procedure (OPCS 4) codes for admitted patient care. Input the relevant information onto the Trust’s encoder, within agreed Trust deadlines. Undertake the coding of inpatient spells, ensuring these are coded accurately and comprehensively. Use the patient administration system to access radiology and pathology results to update coded information not defined at procedure or discharge. Apply knowledge of clinical terminology, anatomical and physiological terms as necessary.

Detailed job description and main responsibilities

• Review and analyse patient records to accurately identify and abstract diagnoses, co-morbidities, complications and procedures relevant to each inpatient episode.
• Assign accurate ICD-10 and OPCS-4 codes in accordance with national clinical coding standards, conventions and guidelines.
• Code complex clinical specialties and deceased patient records, liaising with clinicians where required to ensure accuracy and completeness.
• Maintain high standards of coding quality and productivity, contributing to the delivery of timely and reliable clinical data.
• Provide expert advice on complex coding issues, explaining coding decisions and rationale to clinical, medical and administrative staff.
• Collaborate with clinicians to clarify diagnoses, procedures and emerging clinical practices to support accurate code assignment.
• Share specialist knowledge and provide support, guidance and technical advice to colleagues within the Clinical Coding team.
• Plan and manage a personal workload effectively, working independently to meet agreed objectives and deadlines.
• Contribute to the achievement of monthly coding targets and support team performance during periods of absence or increased workload.
• Use patient administration, pathology, radiology and other clinical systems to gather and validate information required for coding.
• Ensure coded data, patient demographics and admission, transfer and discharge details are recorded accurately and promptly.
• Identify and report data quality issues to ensure patient activity is accurately captured within Trust systems.
• Maintain professional competence through continuous learning, participation in coding reviews and completion of mandatory national refresher training.
• Contribute to the continuous improvement of coding quality, data accuracy and compliance with national standards.