Clinical Coder

ROLES AND RESPONSIBILITIES

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 monitoring of 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 coding.

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.