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The post-holder will be responsible for the clinical coding of inpatient and day-case episodes across all specialties provided at North Tees and Hartlepool Hospitals.
The post involves liaising with clinicians and clinical teams on a regular basis to verify data recorded in patient case-notes and on electronic systems.
The post holder will contribute positively towards the development of the novice clinical coders, will act as mentor to and assist in the training of less experienced coders
Main duties of the job
Abstract clinical information from the electronic patient record to translate into diagnostic (ICD10) and operative (OPCS4) codes in a timely and accurate manner, applying national and international classification rules and conventions.
Work with clinicians to ensure they understand the coding process and its limitations, discuss complex clinical information and convey coding standards and requirements in language understandable by clinicians.
Attend meetings to discuss coding issues and data-quality as required.
Ensure coded data submitted is complete and accurate with full understanding of responsibility for generating the correct financial revenue for the Trust, and impact on Trust’s mortality indicators.
5. Make decision to contact clinician if clinical document is incomplete or appears inaccurate meaning an accurate code assignment can not be made.
6. Ensure coding queries are resolved, escalating to the line manager where necessary.
7. Plan and prioritise own workload to meet performance and quality targets and, in a timely manner, advise the line manager of any hindrance to the achievement of these targets.
8. Ensure monthly departmental deadlines are met, in line with nationally mandated flex and freeze dates, including forward planning of workloads for self and less experienced team members.
Working for our organisation
South Tees Hospitals NHS Foundation Trust and North Tees and Hartlepool NHS Foundation Trust have come together to form University Hospitals Tees. As a result, post holders may be required to work across sites within both organisations.
Across University Hospitals Tees, our ambition is to be the best place to work, ensuring we have the right staff in the right roles at the right time to deliver outstanding patient care and experience.
We are committed to supporting our staff through an inclusive and supportive working environment, offering health and wellbeing initiatives, staff benefits, and opportunities for personal and professional development.
We are committed to fostering an inclusive recruitment process and welcome applications from suitably qualified candidates, including those who first language is not English.
We support the 'Making Every Contact Count' approach to behaviour change in the promotion of health and wellbeing of individuals and communities.
Detailed job description and main responsibilities
Work with clinicians to ensure they understand the coding process and its limitations, discuss complex clinical information and convey coding standards and requirements in language understandable by clinicians;
Liaise with hospital wards and other departments as necessary to chase up outstanding source data;
Work with clinical teams to ensure that palliative care coding is used appropriately and monitored;
Attend meetings to discuss coding issues and data-quality as required;
Improve communication between clinicians and clinical coders regarding the coding process, by meeting and liaising with relevant clinicians on a regular basis agreeing and documenting outcomes;
Liaise closely with coding assistants to co-ordinate timely collection of casenotes in line with departmental deadlines;
Abstract clinical information from the electronic patient record to translate into diagnostic (ICD10) and operative (OPCS4) codes in a timely and accurate manner, applying national and international classification rules and conventions;
Ensure coded data submitted is complete and accurate with full understanding of responsibility for generating the correct financial revenue for the Trust, and impact on Trust’s mortality indicators;
Contribute to improvements in accuracy and completeness of clinical coding for admitted care;
Make decision to contact clinician if clinical document is incomplete or appears inaccurate meaning an accurate code assignment can not be made;
Ensure coding queries are resolved, escalating to the line manager where necessary;
Plan and prioritise own workload to meet performance and quality targets and, in a timely manner, advise the line manager of any hindrance to the achievement of these targets;
Ensure monthly departmental deadlines are met, in line with nationally mandated flex and freeze dates, including forward planning of workloads for self and less experienced team members;
Spend majority of working day at computer, combining accurate keyboard skills with excellent attention to detail;
Maintain speed of work to produce expected level of coded data;
Assist in the continuing development and improvement of the Clinical Coding service in order that high quality-data can be collected and produced with minimum delay;
Support the Clinical Coding Managers and Training and Audit Team to establish a process to allow clinicians to validate and sign-off their own data quality and resolve their queries;
Keep abreast of all new national guidance in relation to clinical-coding practices and ensure own coding skills are kept up to date, widening and strengthening own skill-set across various clinical specialties;
Ensure all ICD/OPCS books are kept up to date with latest guidance;
Undertake appropriate training, as deemed necessary by the Training and Audit Manager and/or Clinical Coding Manager/Deputy Clinical Coding Manager;
Be aware of all statutory and local requirements regarding the disclosure/safe keeping of information e.g. the Data Protection Act, Caldicott etc.;
Support and act as mentor to less experienced coders, and assist with their development;
Participate in discussions relating to general coding problems and issues, for example, at departmental meetings;
Take responsibility for co-ordinating workload to ensure deadlines are met in the absence of Coding Manager/Deputy Coding Manager;
In periods of absence, cover the workload of other colleagues as required;
Provide motivational support to aid staff development.
Person specification
Qualifications & Training
- Educated to GCSE level or equivalent in Mathematics and English
- Basic computer course, e.g. ECDL
- Certificate in Anatomy & Physiology
- Medical Terminology Qualification
Experience
- Attended refresher training and speciality workshops
- Ability to code a wide range of specialty areas
- Previous experience using encoders
Knowledge
- Thorough knowledge of medical terminology, anatomy and physiology
- Good understanding of uses of coded data
- Understanding of confidentiality in the workplace, Data Security and Caldicott
Skills & Attributes
- Ability to extract and analyse complex data from patient clinical records
- Ability to organise own workload and work to Trust deadlines
- Ability to work as part of a team
Management / Supervision
- Act as a mentor for less experienced coders
Communication
- Excellent interpersonal and communication skills, written and verbal
Financial & Physical Resources
- Able to spend extended periods sitting at workstation, concentrating on computer screen
Other
- Flexible approach to work and ability to prioritise workload
- Friendly and able to interact with colleagues
- Professional appearance
- Able to attend training at off-site venues
Important - Once sufficient applications have been received this vacancy may close early.
Disclosure and Barring Checks (DBS)
It is the policy of North Tees and Hartlepool NHS Foundation Trust, that all successful candidates who are new to the Trust who require DBS clearance for the post they have been offered, are required to pay the cost for their DBS certificate. The method of payment for this is via salary deduction from your first month's pay on commencement with the Trust. The DBs check will be undertaken during the pre-employment check screening.
Qualifications
Please note the essential qualifications required for the post are outlined within the Person Specification. You are required to provide original evidence of the necessary qualifications for the post at interview should you be shortlisted. You will also be required to provide original copies as part of the pre-employment check screening.
New Starters – Probationary Period
For any new employees commencing employment with North Tees and Hartlepool NHS Foundation Trust, you will be subject to satisfactory completion of a 6 month probationary period. Please note that internal applications and individuals that are appointed to fixed term appointments of less than 6 months duration are exempt from the probationary period (unless you are an internal applicant currently part way through a probationary period or a bank member of staff).
Employment References
As part of our pre-employment screening process, all applicants are required to provide references covering their last three years employment history including any gaps. Applicants are requested to ensure e-mail addresses for all referees are included on their application form. Personal references are not acceptable.
Working Hours
If the hours advertised for the post are up to full time (37.5 hours per week), applications are still welcomed from individuals who may be seeking to work less
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Senior Clinical Coder employer: NTH
At North Tees & Hartlepool NHS Foundation Trust, we pride ourselves on being an exceptional employer dedicated to providing high-quality care in a supportive and inclusive environment. Our commitment to staff well-being is reflected in our health initiatives, professional development opportunities, and recognition programmes that celebrate the hard work of our team. Join us in Hartlepool, where you can make a meaningful impact in community nursing while enjoying a fulfilling career with a focus on collaboration and respect.
