Clinical Coder

Job overview

QVH places a strong emphasis on the availability of timely, accurate and relevant clinically coded information to assist all staff in the planning and delivery of the best possible healthcare.

Clinical Coding plays a crucial role in the management of the Trust as it directly influences income through the ‘Payment by Results’ process. It also forms the basis for clinical audit, clinical governance reporting, benchmarking, clinical performance indicators, information governance and medical research.

Please note, this may be a Band 3 developmental role for the right candidate who would be required to complete the required competencies before they could move into the Band 4 role.

Main duties of the job

The Clinical Coding Team

• deliver accurate, timely and complete clinically coded data
• fosters a culture of continuous improvement and service development by ensuring all team members have up to date training and that the department participates in regular audit where feedback actions are embedded in every day practice;
• develops strong working relationships with clinicians

The post holder will act as a trainee coder reporting directly to the Clinical Coding Manager. The post holder will ensure that the quality and coverage of coding is constantly monitored and improved, through Clinical Engagement, to provide complete, timely and quality data.

Detailed job description and main responsibilities

Key result areas:

Abstract, analyse and enter correctly coded data into PAS (Patient Administration System) within agreed timescales.

Deal with complicated queries; liaise with clinicians and attend multi-disciplinary team meetings where required.

Locate and collate all appropriate source material, for example, missing case notes, histology.

Liaise with colleagues to distribute workload.

Communication

Able to communicate clearly and with confidence; able to articulate complex rule sets.

Able to offer advice and solutions, demonstrate empathy, attention to detail, leadership, reliability and business acumen on all matters relating clinical coding.

Communicate with Clinicians and Business Unit Management Teams, providing and receiving information that may be of a sensitive or potentially contentious nature.

Take an active part in general departmental meetings to ensure knowledge and learning is widely communicated.

Work with auditors in delivering feedback from audit results, reviewing personal development plans for the team/

Assist clinical teams with the research and provision of information for clinical audit and other purposes.

Ensure appropriate and effective planning, communication and management of clinical coding projects which cross business units.

Maintain and build on specialist knowledge and coding skills through regular peer communication identifying appropriate training opportunities.

Be able in the use of the hospital administration systems for the input of clinical data and the authorised amendment of detail, paying particular attention to accuracy, timeliness and confidentiality and using this knowledge to assist and train others.

Access electronic software systems extract information to supplement clinical coding of the patient record and train others to do likewise.

Regularly review and, if necessary, revise own working practices to take account of the department, Trust and NHS mandatory requirements.

Use knowledge of HSCIC Healthcare Resource Group (HRG) code assignment logic to advise Clinical Coders on diagnostic and procedure code assignment.

Have knowledge of the importance of clinical coding and its uses and an understanding of data quality requirements.

Use and maintain an extended knowledge of medical terminology, anatomy and physiology, to assist in the selection and application of clinical codes and to investigate and resolve possible inconsistencies between source data and test results.

Keep up to date with development and innovations in healthcare provision in Secondary Care.

Analytical and Judgmental

Work with the Information, Contracting and PAS Teams to improve data quality.

Abstract and analyse complex patient clinical records.

Use judgement to escalate complex cases where the procedure undertaken may not be readily code-able.

Use judgement to resolve complicated coding queries on behalf of the team where information available is ambiguous or there is differing opinion.

Be familiar with external clinical coding audit requirements, and standards, meeting with external auditors as and when required.

Applicant requirements

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.