Trainee Clinical Coder

Job overview

An opportunity has arisen for a highly motivated and enthusiastic individual to join our clinical Coding Team.

Clinical Coding is the translation of medical terminology as written by the clinician to describe a patient's complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a code form which is nationally and internationally recognised. Clinical Coders knowledge and skill enable information to be collected to support the delivery of healthcare, to promote health and support payment systems. Accuracy and attention to detail are essential as is an understanding of anatomy and physiology and medical terminology. You will have excellent communication skills and the ability to work under pressure to meet reporting deadlines. Ideally you will have coding experience or be qualified in the National Clinical Coding Qualification (UK) (NCCQ). If you are an unqualified please note whilst there will be training and support provided, those going through the exam process are expected to undertake extensive self-learning and revision in their own time. A flexible approach to work is essential.

An aptitude test will be required to be passed by shortlisted candidates before being offered an interview.

Main duties of the job

The Clinical Coder will be responsible for producing and maintaining an efficient and high-quality clinical coding service to support data quality, and medical audit, thereby supporting the allocation of accurate Healthcare Resource Groups (HRGs) for costing and other analysis.

To provide an efficient and high quality diagnostic and procedural coding service ensuring, through participation in audits of the coded clinical data, that the coded clinical data meets the required national and international classification rules and conventions.

To maintain accurate and comprehensive clinical coded data which has a direct impact on the finance and funding for the Trust.

To maintain knowledge base and to work unsupervised on routine coding issues, applying knowledge of the latest developments in clinical coding, taking advice from the experienced team members when appropriate.

To take responsibility for own professional learning and development over and above that which is supplied by the Trust.

To ensure that clinical data is entered into the Patient Administration System (PAS) for every patient within an agreed time period from discharge in line with Secondary User Service submission deadlines.

Requirement to consistently deliver against demanding deadlines and accountable for maintaining accuracy and compliance with frequently changing national standards and clinical coding conventions.

Detailed job description and main responsibilities

• Through training and experience, to have a good working knowledge of anatomy and physiology and medical terminology.
• To provide an efficient and high-quality diagnostic and procedural coding service ensuring, through participation in audits of the coded clinical data, that the coded clinical data meets the required national and international classification rules and conventions.
• To maintain accurate and comprehensive clinical coded data which has a direct impact on the Finance Department and funding for the Trust.
• To maintain knowledge base and to work unsupervised on routine coding issues, applying knowledge of the latest developments in clinical coding, taking advice from the experienced team members when appropriate.
• To ensure that clinical data is entered into the Patient Administration System (PAS) for every patient within an agreed time period from discharge in line with Secondary User Service submission deadlines.
• Requirement to consistently deliver against demanding deadlines and accountable for maintaining accuracy and compliance with frequently changing national standards and clinical coding conventions.
• Following successful completion of initial training, under the direction of the coding manager and senior team work autonomously without direct instruction or supervision when self-allocating work and achievement of daily/weekly/monthly coding targets.
• To interpret histology and radiology reports to ensure completeness and accuracy of the coding process.
• To ensure that an efficient cancer registration service is maintained.
• To comply with both Trust and Departmental policies and procedures, adhering to local coding policies as appropriate.
• In liaison with the Clerical Officer and other Trust staff, determine the location of missing health records, to ensure targets are met.
• To investigate incorrect patient coded data and liaise with the appropriate staff to correct the data on PAS.
• To advise, support and mentor less experienced staff on coding issues.
• To provide cover for colleagues’ absence during holidays/sickness/etc. to ensure continuity of data collection, coding, and deadlines.
• To communicate effectively with clinicians, nursing staff, other healthcare professionals and departments, both internal and external, concerning routine coding issues.
• To undertake to attend relevant training/workshop sessions, both internal and external to the Trust, this will require travel off site to various locations.
• Attain the National Clinical Coding Qualification within 3 to 4 years of successfully completing the Clinical Coding Standards Course.
• Undertake any additional duties to support the needs of the service as directed by the coding manager and/or senior team.

Once the appropriate knowledge and skills have been developed and the National Clinical Coding Qualification attained, there will be a requirement:

To deputise for senior team members in their absence