Senior Clinical Coder in Essex, Harlow

To provide an efficient and high-quality clinical coding service to support the business needs of the Trust, including Clinical Governance, Information Governance and finance by ensuring accurate translation and input of medical terminology. To act as an expert senior Clinical Coder, guided by occupational policies, assisting coders with complex coding queries, providing expert advice to other departments on coding issues. To support in the leading of the coding team assigned to support a specific area of Clinical work. You will be responsible for ensuring that coding deadlines are met and working with senior staff within the department for ensuring that staff are adhering to national and local coding standards, policies and guidelines. To analyse and extract diagnostic and procedural information from patient case notes and information systems and assign the appropriate code, in accordance with local and national coding practices in an accurate and timely fashion.

Main duties of the job

• Support Clinical Coding Specialist Health Group Lead to ensure targets are met within the specified timescale.
• Support Clinical Coding Specialist Health Group Lead in all aspects to ensure smooth running of the department.
• Work according to Trust / National policies.
• Mentor coders for accuracy and consistency of Coding.
• Awareness of Data Protection Act; always maintain Patient Confidentiality.
• Extract, analyse, and translate complex clinical information from patient cases notes allocating accurate diagnosis & operational procedure codes.
• Code finished consultant episodes for all sites of the Trust.
• Communicate complex coding rules.
• Liaise with Clinicians/Information/Finance and other departments/agencies.
• Work with Divisions, to promote Clinical Coding and the level of clinical information that is required to support the high quality of coding.
• Support in the Resolution coding queries from across the Trust.

About us

The Princess Alexandra Hospital NHS Trust (PAHT) is proud to care for the communities of West Essex, delivering safe, compassionate, and high-quality services. We are part of the Neighbourhood Wave; a national programme that’s changing how care is delivered by focusing on prevention, early support, and more joined-up services across health, social care, and the voluntary sector. This means we’re working more closely with local partners to bring care closer to home and support people to live healthier, more independent lives. We’re a supportive and inclusive organisation that values its people. We offer development opportunities, flexible working, and a strong focus on wellbeing. As a Disability Confident and equal opportunities employer, we welcome applicants from all backgrounds and experiences. Join us and help shape the future of care in West Essex.

Job responsibilities

• To identify uncoded activity by reviewing the daily discharges reports / uncoded reports.
• Using clinical documentation on AlexHealth to identify, analyse, extract and interpret complex information relating to the patients stay.
• Using other source documentation and systems to identify, analyse, extract and interpret complex information relating to the patients stay.
• Using coding tools (Coding Standards, ICD and OPCS classification books, coding clinics and Classification Service resolutions) to identify the codes to be applied to each Finished Consultant Episode.
• At all times adhering to national standards and local coding policies exercise judgement and initiative in selecting the appropriate clinical codes to ensure that the coding accurately reflects the individual patient episode.
• To access a variety of information systems, e.g. Ophthalmology, Endoscopy, and other clinical systems in use at the Trust, to obtain other information to inform the coding process and to ensure the completeness and accuracy of coding.
• To use own discretion and judgement to analyse often complex information available using coding rules and conventions to translate this information into the appropriate codes as set out by national guidance (OPCS 4.10 Office ICD-10) or any classification that may be implemented in the future.
• To enter coded clinical data onto the Trust encoder (Solventum Medicode 360) ensuring accuracy, completeness and timeliness at all times as failure to code episodes accurately will have a direct effect on Trust reporting.
• To routinely code a minimum of 40 episodes per day on average.
• To identify data quality queries on the patient information system, for example patients not admitted, transferred and discharged, wrong Consultants and dates and address the issue with the Data Quality team, while ensuring the Assistant Clinical Coding Manager is aware.
• To negotiate with clinicians over interpretation of coding guidance, escalating to the Assistant Coding Manager as appropriate.
• To deal with coding queries as and when necessary throughout the working day and to communicate complex coding rules to medical, clinical, administration staff.
• To be responsible for prioritising the workload of your Team using the uncoded reports available, ensuring that the departmental targets are met and to advise the team leader of any hindrance to the achievement of these targets, providing support and supervision to more junior coders.
• Communicating complex coding rules and key terms and conventions to these staff groups, working to ensure that the coding reflects the patients’ clinical condition and treatment and that the Income generated (via HRG allocation) is accurate.
• To support the Clinical Coding Specialist Health Group Lead in motivating all staff in the Coding Team by discussion and analysis to ensure that the Clinical documentation and the subsequent Clinical coding is of a high quality.
• To participate in discussions of coding problems and issues with other clinical coders, for example at monthly departmental meetings.
• To demonstrate a high degree of compliance and discipline in accordance with complex changing terminology and their relationship to new surgical techniques and all new changes in the diagnostic field as related to the classifications and medicine.

This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.

Person Specification

Qualifications

• Essential: Accredited Clinical Coder qualification or equivalent experience.
• Attainment of the Clinical coding foundation Course.
• Evidence of attendance to a Clinical Coding refresher course, within the last 2 years.
• Desirable: Evidence of post graduate qualification or equivalent experience in managing a performance output-based service.
• Evidence of attendance on Clinical coding speciality workshops, within the last 2 years.
• Leadership and Management qualification (training will be given).
• Approved Clinical Coding Auditor or Trainer Qualification.
• Degree in an anatomy or physiology related subject.

Experience

• Essential: Evidence of Continuing professional Development.
• Demonstrable in-depth specialist Clinical Coding experience across a wide range of Specialities, in an Acute Trust setting.
• Experience of using Patient Administration systems and encoding software.

Skills and knowledge

• Excellent working knowledge of the National Tariff payment System (formerly known as PbR).
• Demonstrable and extensive understanding of Anatomy & Physiology and Clinical Terminology.
• Comprehensive knowledge of coding rules and Classifications.
• Use of MS Word & Excel to an intermediate level.

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.