Senior Clinical Coder

Job summary

Main duties of the job

• Screen medical records, discharge summaries, histopathology results and other data sources to extract clinical information relevant to a patients episode of care.
• Through effective data extraction analyse complex clinical information; apply independent judgement in the interpretation, transposition and sequencing of clinical data adhering to national rules and conventions.
• Code all patient episodes using the M360 Solventum encoding system supported by International Classification of Diseases (ICD 10) and Office of the Population of Censuses and Surveys (OPCS 4) coding classifications.
• Exercise initiative in selecting appropriate clinical terms to accurately reflect the individual patient record.
• Ensure data is entered accurately into the Patient Administration System (PAS) within national defined timescales.
• Regularly required to access and read patient case notes where the content can be distressing.
• Develop and maintain skills to use the PAS system and adhere to local coding protocols/procedures.
• Check patient details held on the system are correct e.g. consultant, date of admission and discharge reporting any incorrect details to the Data Quality Team.
• Routinely run outstanding episode reports from the Patient Administration System and action by searching for missing source documentation.
• Code complex specialties including mortality coding.
• Maintain and update knowledge in accordance with national clinical coding standards changes.

Job responsibilities

We are an acute trust caring for over one million people in Wakefield and Kirklees. Our 10,000 staff members work in patients homes, the community, and our three hospitals in Pontefract, Dewsbury, and Pinderfields (Wakefield). Committed to continuous improvement, we prioritise our people and values so we can deliver excellent patient experience. Our team is friendly, passionate and always seeking better ways to work through research and innovation.

We support work-life balance and foster a diverse, inclusive environment where everyone belongs. Our staff networks offer safe spaces for honest conversations and to share ideas, thoughts and concerns so we can increase awareness and appreciation of equality, diversity, and inclusion. As a member of the team, you will have access to the NHS pension plan, a generous holiday allowance, employee health and wellbeing services and extensive benefits and support. These include onsite nurseries, childcare vouchers, home electronics schemes, working carers support, carer-friendly policies, and more.

If you value caring, high standards, improvement, and respect, join the MY team to make a difference every day.