Clinical Coder

Job overview

Would you like to join our Clinical Coding team as a Clinical Coder? Read on to learn more about this rewarding role and submit your application.

The Clinical Coding service is a part of the Digital Division of the University Hospitals of Leicester and is responsible for extracting and codifying complex clinical information that describes a patient's diagnostic and procedural healthcare status within an episode of care in a timely manner.

The ability of UHL to accurately record and codify its clinical activity is fundamental to understanding the quality of its clinical services. Our coded data is used by all parts of the Trusts business to deliver trusted and high-quality services to patients.

Accredited Clinical Coders are a core component of the Clinical Coding service and have a crucial supporting role in the overall management of the Trust as their output directly influences income through the NHS Payment Scheme

Main duties of the job

Extraction of complex clinical information from the health record on discharge of the patient and translation of medical terminology using ICD10 and OPCS4 into a form that can be tabulated, aggregated and sorted for statistical analysis, applying national and international rules and conventions to agreed standards. Training and workshops will be provided by our team of Trainers. All coders will attend workshops on a regular basis to enable them keep up to date with any changes within clinical coding and support learning skills and development

Detailed job description and main responsibilities

1. To accurately analyse, interpret and extract relevant clinical information and data (including complex conditions, treatments and High Cost Drugs) from a variety of electronic sources including Badger (Neonatal Care), CITO (scanned patient documents), CRIS (imaging reports), DICT3, Euroking E3 (Maternity admissions), Heart Suite (paediatric cardiology & surgery), ICE (discharge letters), iLab (pathology results), Intellect Web (cardiac surgery/cardiology), Medisoft (ophthalmology), Nerve Centre, ORMIS, Proton and Unisoft (endoscopy reports).

2. Responsible for managing own workload within broad guidelines. Have a joint goal with other coders to achieve coding targets.  Assist colleagues with coding patient case notes if necessary, to ensure all coding is completed within the Trust’s stated deadlines. This may include mentoring less experienced colleagues.

3. Responsible for identifying obstacles to meeting these deadlines and for taking appropriate action to overcome them.

4. Responsible for identifying and analysing patterns of errors and notifying these to manager, with proposed potential solutions.

5. To comply with both the Trust and departmental policies and procedures and implementing local policies when required.

6. To work with Clinicians to improve the quality of clinical coded information across the Trust, participating in multi-disciplinary team meetings as a coding expert.

7. To be a key knowledge resource for and assist with the development of documentation of coding processes, procedures and protocols to ensure quality and consistency within the hospital and adherence to national and international guidelines. Be responsible for the on-going revision and documentation of these processes.

8. Assist with Mentoring and developing inexperienced staff to enable them to exercise their own initiative in selecting appropriate clinical terms to accurately reflect the patient’s episode of care.

9. To undertake a program of Continuous Professional Development, to ensure professional coding skills and knowledge are kept up to date and maintaining the ability to work autonomously to the highest professional standards.

10. The post holder will be expected to have the ability to code more than one specialty.