Qualified Clinical Coder

Job overview

To provide an efficient and high-quality clinical coding service to support the business needs of the Trust, including Clinical Governance, Information Governance and finance by ensuring accurate translation and input of medical terminology.

To act as an expert senior Clinical Coder, guided by occupational policies, assisting coders with complex coding queries, providing expert advice to other departments on coding issues.

To support in the leading of the coding team assigned to support a specific area of Clinical work. You will be responsible for ensuring that coding deadlines are met and working with senior staff within the department for ensuring that staff are adhering to national and local coding standards, polices and guidelines.

To analyse and extract diagnostic and procedural information from patient case notes and information systems and assign the appropriate code, in accordance with local and national coding practices in an accurate and timely fashion.

Main duties of the job

• To identify uncoded activity be reviewing the daily discharges reports / uncoded reports
• Using clinical documentation on AlexHealth to identify, analyse, extract and interpret complex information relating the patients stay.
• At all times adhering to national standards and local coding policies exercise judgement and initiative in selecting the appropriate clinical codes to ensure that the coding accurately reflects the individual patient episode.
• To use own discretion and judgement to analyse often complex information available using coding rules and conventions to translate this information into the appropriate codes as set out by national guidance (OPCS 4.10 Office ICD-10) or any classification that may be implemented in the future.
• To routinely code a minimum of 40 episodes per day on average.
• To negotiate with clinicians over interpretation of coding guidance, escalating to the Assistant Coding Manager as appropriate.
• To deal with coding queries as and when is necessary throughout the working day and to communicate complex coding rules to medical, clinical, administration staff.
• To support the Clinical Coding Specialist Health Group Lead in motivating all staff in the Coding Team by discussion and analysis to ensure that the Clinical documentation and the subsequent Clinical coding is of a high quality.

.   To participate in discussions of coding problems and issues with other clinical coders, for example at monthly departmental meetings.

Detailed job description and main responsibilities

• Please see the attached Job description and person specification. This is available to download at anytime.