Trainee Clinical Coder

Job overview

A Clinical Coder is responsible for the extraction and analysis of complex clinical information from clinical documents/systems relating to a patient’s episode in hospital. The Clinical Coder translates the medical terminology applying relevant national clinical coding standards into codes from Classifications used nationally and internationally and record these as a key component of the patient’s clinical history. They will use judgement to translate complex cases where a procedure or diagnosis may not be readily codeable.

The post-holder will participate fully in the Standards Training Course for Clinical Coding as well as other internal clinical coding courses that make up a comprehensive Training programme. After successful qualification the post holder will be supported in working towards the Accredited Clinical Coding qualification (ACC).

Main duties of the job

• Retrieve and interpret clinical information from electronic patient record and other clinical source documents/systems, check data quality and record necessary amendments
• Term and encode clinical information in accordance with national guidance for clinical coding and classification systems and with local policies and procedures
• Abstract and analyse clinical terms from EPR and other relevant clinical source systems using judgement to obtain the correct diagnosis and procedure codes where details may be complex or conflicting.
• Apply clinical coding rules and conventions, seeking help from the Senior Clinical Coder as required.
• Ensure that coded clinical information is timely, complete, and accurate to support National Payment Tariff System.
• Keep abreast of any proposed changes to the clinical coding process and changes within the customer organisations which may impact on the clinical coding process

Detailed job description and main responsibilities

• Retrieve and interpret clinical information from electronic patient record and other clinical source documents/systems, check data quality and record necessary amendments
• Term and encode clinical information in accordance with national guidance for clinical coding and classification systems and with local policies and procedures
• Abstract and analyse clinical terms from EPR and other relevant clinical source systems using judgement to obtain the correct diagnosis and procedure codes where details may be complex or conflicting.
• Apply clinical coding rules and conventions, seeking help from the Senior Clinical Coder as required.
• Ability to identify and highlight any Clinical Coding issues and look to resolve such issues by liaising with the Senior Clinical Coder
• Liaise with clinical staff to ensure correct interpretation of clinical information
• Ensure that coded clinical information is timely, complete, and accurate to support National Payment Tariff System.
• Keep abreast of any proposed changes to the clinical coding process and changes within the customer organisations which may impact on the clinical coding process
• Work on your own initiative, prioritising workload as required.
• Be prepared to self-study and research on the internet.
• Carry out any other duties and responsibilities commensurate with the grade.
• Be aware of our customer requirements
• Be aware of developments within THIS
• Participate in delivery of work programmes
• Manage own work to deliver agreed programmes on time and in full
• Responsible for your own monthly time sheets and completing AMS (Activity Management System) ROD (Remedy on Demand) on a regular weekly basis
• Observe personal duty of care when using office equipment and machinery
• Attend all mandatory training
• Participate annually identifying, developing, and agreeing your own development plan with your Line Manager using the Trust Appraisal
• Comply with all Trust policies, procedures, and protocols.
• Carry out duties with due regard to the Trust’s Equal Opportunity Policy.
• Seek advice and support from Line Manager whenever necessary.
• Maintain professional conduct including appearance at all times