B5 Senior Clinical Coder

Job overview

About Us:

The Clinical Coding Department at Epsom and St Helier University Hospitals is a vital part of our healthcare system. We are responsible for accurately translating patient information into codes that are used for billing, research, and planning purposes. Our work directly impacts the Trust's ability to recover income and plan services effectively.

Our Team:

Our team is comprised of skilled and dedicated professionals who are committed to delivering high-quality work within demanding time frames. We work closely with clinicians, medical secretaries, and other staff to ensure that all relevant information is captured and coded accurately.

Main duties of the job

• To abstract and analyse complex clinical information from patient records and translate this into a coded format in line with National Standards. To have a high level of knowledge of Medical Terminology and Anatomy and Physiology.
• To enter the final encoded data onto the appropriate computer systems to meet essential Trust requirements for statutory information and financial flows.
• The post holder will work as part of a team of experienced trained and trainee staff and the job will involve rotation between duties working on all specialties across all the five teams.
• Deal with enquiries from all parts of the hospital.
• Locate source documents; read histology, cytology, and radiology reports and analyse complex medical information from the EPR.
• Ensure that patient records are processed in the correct manner and tracked to appropriate destinations using the computer tracking system.
• Act as mentor and assist in the education of less experienced coders.
• To be aware of wider information and patient administration service systems.

Detailed job description and main responsibilities

Abstract pertinent information from patient case notes and other relevant sources, detailing primary diagnoses, co-morbidities, operations, investigations, and treatments for each care period provided to patients. Utilize knowledge and experience to translate this data into ICD-10 and OPCS-4 codes, ensuring accuracy and adherence to coding conventions. Enter the coded information promptly and accurately into the hospital's Patient Administration System, following established guidelines for International Classification of Diseases and OPCS procedure books.