Clinical Coder

Clinical Coder

The post holder must have attended the 21 day standards course, had 18 months experience coding in UK, participated in on-going training initiatives both on and off site e.g. refreshers, specialty workshops etc and be working towards attaining the NCCQ in order to achieve the ACC status.

To provide high quality and timely coded clinical data through effective data extraction and analysis of complex clinical information, independent judgment in the interpretation and sequencing of clinical data, adhering to national rules and conventions of International Classification of Diseases and Related Health Problems (ICD-10) and OPCS Classification of Interventions and Procedures (OPCS-4). It is essential to ensure the data is accurate and complete in order to meet the Trust's monthly deadlines for statutory information requirements to support HRGs (Healthcare Resource Groups), Service Line Reporting, Clinical Governance and to facilitate maximisation of the Trust income in line with the PbR (Payment by Results) scheme.

The successful applicants will provide a vital and dynamic role in supporting delivery of the clinical coding service. The coding function has an enviable high profile throughout the Trust, allowing coders the opportunity to work with individual clinicians and clinical divisional leads. The successful candidates will be directly accountable for improving coding quality through clinical engagement, ensuring the ongoing accuracy of clinical coding as well as meeting Trust's deadlines associated with clinical coding. Increased demand for higher quality clinical coding and quicker turnaround times mean opportunities for new ways of working and we need people who can deliver. This role will require great attention to detail, excellent concentration span and logical thought process. You will need to be dynamic, enthusiastic and methodical. The candidates should have attended the foundation course and will require to have some coding experience.

Other essential skills include excellent written and verbal communication skills to effectively communicate with clinical coders, auditors, clinicians and management.

Chelsea and Westminster Hospital NHS Foundation Trust is one of England's top-performing and safest trusts. We operate two main acute hospital sites--Chelsea and Westminster Hospital and West Middlesex University Hospital--along with award-winning clinics across North West London.

Our nearly 7,500 staff care for a diverse population of 1.5 million, providing full clinical services, including maternity, A&E, and children's services, plus specialist HIV and sexual health clinics. The Care Quality Commission rates us 'Good' in safety, effectiveness, care, and responsiveness, and 'Outstanding' in leadership and resource use.

We continually invest in our facilities, including a £30m expansion of critical care at Chelsea and Westminster and an £80m Ambulatory Diagnostic Centre at West Middlesex.

We are committed to equal opportunities and believe that diversity drives innovation and excellence. As part of our dedication to equity, we actively welcome applications from individuals from the global majority, veterans and underrepresented communities. We value the unique perspectives and experiences that diverse teams bring and are committed to creating an environment where all voices are heard, respected, and empowered to succeed.

If you haven't heard from us within three weeks of the closing date, your application was likely unsuccessful. Employment is subject to a six-month probationary period.

Some roles may require weekend shifts at multiple sites.

Job responsibilities include using a range of complex and sensitive source documents both manual and electronic, undertake abstraction, analysis and translation of clinical data for all in-patients and day-case finished consultant episodes (FCEs), following the rules and conventions of ICD-10 and OPCS-4. This information often includes exposure to highly disturbing narrative of patients diagnosis, prognosis and photographs. Coding will be carried out under close supervision of a senior qualified coder in accordance with levels of knowledge and confidence which will increase throughout the training period.

Input coded clinical data onto the Trusts patient administration system, under supervision, using encoding software. To plan and prioritise work to ensure accurate, complete and timely recording on Lastword to meet departmental targets (completion of coding within 5 days of the episode end date) and to advise the line manager of any hindrance to the achievement of these targets.

To manage and prioritise own workload for the outstanding uncoded episodes within the department, providing cover for colleagues as and when required. To work as part of the team to produce accurate, complete and meaningful clinical coded data. To participate in the process of routine audits or reviews of coded data and all aspects of the clinical coding function to ensure provision of accurate and qualitative coding standards.

In accordance with level of expertise and knowledge gained throughout the training/educational process and under supervision where required, code to professional standards and conventions to ensure that high quality clinical coded data are provided within agreed time scales. This will require focus, motivation, judgment and analysis of highly complex clinical information.

To receive and absorb appropriate clinical coding training in ICD-10, OPCS-4 classifications and anatomy and physiology to required national standards. To undergo ongoing monitoringof coded work as part of professional development, taking part in feedback sessions. Accept critical judgment of work and apply all standards learnt as part of the clinical coding training process.

To identify own training and development needs and undertake appropriate training/education as required. Non- accredited clinical coders to work towards National Clinical Coding Qualification Exam (NCCQ), in order to achieve the ACC status.

Understand the impact of coded data on the business aspects of the Trust, and thus be able to provide the information and advice to all health professionals and administrative staff of the nature and complexity of clinical coding and its purposes in areas such as patient care, clinical governance, clinical audit, finance, budgeting, data quality and research.

To access and examine all appropriate clinical documentation sources to obtain the necessary clinical patient data and to actively liaise with senior clinicians to verify incomplete or contradictory clinical data; reporting complex coding queries, documentation and systems data quality inconsistencies to the Senior Clinical Coders or the Clinical Coding Team Managers.

To ensure maintenance of a portfolio of evidence and professional accreditation through attendance and participation in ongoing internal and external training programmes; continuously updating comprehensive knowledge and understanding of medical terminology, anatomy and physiology and its applications to clinical coding.

Maintain a flexible attitude and response to change in job content or organisation in order to maintain or improve the quality of service provided to patients, the Trust and to other customers.

To participate in complex multi-disciplinary audits, regular speciality based coding audits, both internal and external as required. With the Clinical Coding Auditor ensure corrections resulting from the outcome of audits are made and that all recommendations are acted on, delivered and become sustainable best practice.

The post holder is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job and other training as required in order to keep clinical coding skills and knowledge base completely up-to-date.

To maintain and update as necessary a personal copy of the relevant clinical coding instruction manuals in accordance with national standards.

To comply with both the Trust and departmental policies and procedures. To contribute relevant information and assist in the ongoing development and maintenance of Clinical

To participate in an annual individual performance review process where objectives will be agreed, performance monitored and personal development needs discussed.

To attend all statutory and mandatory training as and when required to do so.

Be accountable for all equipment and resources within the designated work area and report any related problems to line management.

To ensure that Health and Safety guidelines are followed; and, to ensure that full compliance is adhered to regarding the Confidentiality Policy and Data Protection Act.

Any other duties as requested by the Clinical Coding Team Manager or the Head of Clinical Coding within the scope of the job profile as required.

Demonstrable evidence of being able and willing to understand our Trust values of respect, kindness, excellence and safety, with behaviour that reinforces these values.

This job description is not intended to limit the scope and extent of the job to be undertaken and will be subject to review and alteration as necessary, following discussion with the post holder.

Communication: Ensure all communication, which may be complex, contentious or sensitive, is undertaken in a responsive and inclusive manner, focusing on improvement and ways to move forward. Ensure all communication is presented appropriately to the different recipients, according to levels of understanding, type of communication being imparted and possible barriers such as language, culture, understanding or physical or mental health conditions.

These duties are not exhaustive and will be reviewed with the postholder, allowing for amendments within the broad scope and band level of the role.

Person Specification

Education and Qualifications

Essential

• Clinical Coding Standards Course
• High degree of knowledge in Anatomy & Physiology
• Sound knowledge of Payment by Results and HRGs

Desirable

• Academic achievements to a degree level

Experience

Essential

• 18 months clinical coding experience
<