Trainee Clinical Coder

Job overview

An exciting opportunity has arisen to join our Clinical Coding team as a Trainee Clinical Coder. This is a post for someone who wants to build a career translating clinical information into the coded data that underpins patient care, service planning and Trust income.

You will follow a structured training programme combining national and local training, supervised practice and competency-based progression, working towards passing the Clinical Coding Standards Course. You will learn to abstract, analyse and translate clinical documentation into ICD-10 and OPCS-4 codes, working within designated training specialties under close supervision from other coders and the training leads.

No previous coding experience is needed. We're looking for someone with 5 GCSEs at grade 4/C or above (including Maths, English and Biology or Combined Science), accurate computer and data-entry skills, a strong eye for detail, and the commitment to study towards a professional qualification. Experience in an NHS or healthcare setting is welcome but not essential.

You'll need to attend the department full-time until assessed as competent to work independently, after which hybrid working is available. Initially, you will also be required to assist with the location of case notes for coding and other clerical work.

In return, you'll join a supportive, values-driven team that invests in its people, with a clear development pathway from trainee through to qualified experienced coder.

Main duties of the job

Working under close supervision, you will:

• Undertake supervised clinical coding of inpatient and day-case activity within designated trainee specialties, following national standards and local instructions.
• Learn to abstract, analyse and translate clinical information from patient documentation, applying ICD-10, OPCS-4, sequencing rules and national conventions with guidance. This involves 25 days classroom based training.
• Retrieve missing clinical information such as notes, reports and test results as directed.
• Escalate all unclear, incomplete or ambiguous documentation, and any coding query beyond your current competence, to supervising staff.
• Submit all coded work for checking and validation, responding positively to feedback and acting on any errors identified.
• Use EPR, PAS, ICE and other systems safely at trainee level, reporting technical issues to senior colleagues.
• Handle patient information securely and confidentially in line with GDPR, Caldicott, DSPT and Trust information governance policies.Follow the departmental training plan, attending supervised coding sessions, team meetings and learning activities, and working through competency requirements towards becoming an accredited clinical coder.
• Maintain clear working notes, coding examples and development logs for review.

Please note that all coded work is checked until you are formally signed off in a specialty; this post does not code independently.

Detailed job description and main responsibilities

A Trainee Clinical Coder is an entry-level member of the Clinical Coding team, learning the foundational knowledge and skills required to become an independently competent Clinical Coder. The post holder will follow a structured training programme of national and local training, supervised practice and competency-based progression, building towards the National Clinical Coding Qualification (NCCQ) at Band 4 in line with departmental expectations.

Please refer to the job description and person specification for further information on the role