Senior Clinical Coder

Job overview

This vacancy is subject to Recruitment & Retention Premium of 15% (reviewed every 12 months)

Clinical Coding has a crucial role in the management of the hospital for contractual/billing purposes, due to the implementation of Payment by Results and is a source of healthcare data for the Department of Health (DOH) and World Health Organisation (WHO).

The post holder is responsible for providing high quality and timely coded clinical data.  This requires the application of all coding rules and conventions pertaining to ICD-10 (International Classification of Diseases, Version 10) and OPCS-4 (Classification of Interventions and Procedures), incorporating national standards as set down in the Clinical Coding Instruction Manual ICD-10, OPCS-4 and Coding Clinics

The post holder would have the initiative to extract all necessary medical information via patients’ health records and a wide range of hospital information systems for the coding to be completed within set timeframes.  Ability to organise and prioritise workloads, meet deadlines and tackle problems systematically is of paramount importance

To be competent in coding specialties across the organisation

Patient and departmental confidentiality must be maintained at all times.

Main duties of the job

• Responsible for the abstraction, analysis and interpretation of complex and highly complex clinical information found within patient’s health records, use judgment and knowledge in assigning the correct codes when the information provided is conflicting.
• Translate and assign the most accurate clinical codes for diagnosis, co-morbidities and procedures undertaken for all discharged and transferred patients.

Detailed job description and main responsibilities

• Responsible for the abstraction, analysis and interpretation of complex and highly complex clinical information found within patient’s health records, use judgment and knowledge in assigning the correct codes when the information provided is conflicting.
• Translate and assign the most accurate clinical codes for diagnosis, co-morbidities and procedures undertaken for all discharged and transferred patients.
• Ensure strict adherence to procedures established for clinical coding as laid out by the classifications in use and take into account changes made to the classification should the need arise.
• Participate in regular training sessions in order to develop and enhance coding speciality skills.
• Update national classification books and manuals in line with national standards released by the NHS Classification Service.  For example Coding Clinics
• Demonstrate a high level of skills in the use of International Classification of Diseases, volume 10 (ICD-10) and the Classification of Interventions and Procedures, (OPCS-4).
• Identify and report errors found on the Patient Administration System e.g. incorrect consultant designation.
• Work with specialty divisions to support and maintain a professional and flexible coding service.
• Ability to code specialties at a high level of accuracy and to rotate as and when required, with appropriate support and training.
• Attend multi-disciplinary meetings for assigned specialities/wards.
• Provide specialist advice to clinical and non-clinical staff with regards to clinical coding.
• To ensure that working processes are followed in own area of work and ensure and initiate service review when these processes are no longer effective providing suggestions for development when required and implementing agreed revisions.
• Provide cover for absence of clinical coding staff, as required ensuring continuity of service provision
• Ensure that health records tracking is maintained if required
• This job description covers the major tasks to be carried out and the level of responsibilities to which the post holder will work.  These may be revised and changed from time to time. Discussions will take place with the post holder.