Clinical Document Coder/Administrator - ELA -FT/PT available

Job description

Job responsibilities

This Job Description is solely a guide and an example of the kinds of job duties that the post holder is expected to undertake.This job description is not intended to be a complete list of duties and is subject to review as the work of the department develops and resources change.

Key Responsibilities

• To extract the clinical information from the manual and computerised patients health records and then analyse that information to assign appropriate clinical codes, with adherence to the rules, regulations and protocols of clinical coding using the GPs clinical computer system.
• To understand, and maintain, the need for accuracy of clinical coding as this has a direct impact on the revenue generation and funding for the Practice.
• To provide cover for absence of coding staff, as required, ensuring continuity of data coding.
• To possess sufficient knowledge once trained to work unsupervised on routine coding, taking advice from a supervisor when appropriate.
• To effectively communicate with coding team, doctors, nursing staff and others concerning coding issues.
• To resolve any coding queries by consulting with line manager, colleagues and by liaising with other medical staff.
• To be able to manage own workload to ensure work is accurate and complete to meet targets and communicate any problems to the Line Manager. Undertake other duties as required commensurate with the post. To work mainly on own initiative but referring more complex issues to colleagues or Line manager.
• To always maintain confidentiality of all coded and other patient data in line with the Data Protection Policy.
• To attend any meeting that is appropriate as necessary.
• To comply with ELAs policies and procedures and implementing local policies when required.
• To undertake the necessary training courses to develop a good knowledge of Clinical Coding and surrounding coding issues.
• To undertake all reasonable requests from Line Manager.

An ability to adapt to new circumstances will be essential.

Confidentiality & Information Governance

• Confidentiality is of prime importance. In the normal course of duties, the post holder will have access to confidential documents and information relating to patients, service users, staff, and contractors, as well as information of a commercially sensitive nature.
• Such information should not be communicated to anyone outside or inside the NHS unless done in the normal course of carrying out the duties of the post. Disciplinary action will be considered where a breach of confidence has been established
• All information obtained or held during the post-holders period of employment that relates to the business of the ELA and its service users and employees will remain the property of the ELA
• Information may be subject to disclosure under legislation at the Trusts discretion and in line with national rules on exemption
• The post holder must maintain high standards of quality in corporate and clinical record keeping ensuring information is always recorded accurately, appropriately and kept up to date.
• The post holder must only access information, whether paper, electronic or in other media, which is authorised to them as part of their duties
• The post holder must ensure compliance with the Data Protection Act 2018.

Health & Safety at Work

The post holder is required to take reasonable care of the health and safety of themselves and other persons who may be affected by their acts or omissions at work and to co-operate with the ELA in adhering to statutory and departmental safety regulations

• The post holder is responsible for ensuring that they do not intentionally or recklessly misuse or interfere with anything provided in the interests of health safety or welfare e.g., misuse of equipment
• The post holder is required to contribute to the control of risk and must report immediately, using the ELA Incident reporting system, any incident, accident or near miss involving patients, service users, carers, staff, contractors, or members of the public

Quality

The post-holder will strive to maintain quality within the practice, and will:

• Alert other team members to issues of quality and risk
• Assess own performance and take accountability for own actions, both directly and under supervision
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance
• Work effectively with individuals in other agencies to meet patients needs
• Effectively manage own time, workload, and resources

Communication

The post-holder should recognise the importance of effective communication in the team and strive to:

• Communicate effectively with colleagues, patients, carers, and anyone else associated with the role
• Recognise peoples needs for alternative methods of communication and respond accordingly

Person Specification

Qualifications

Essential

• Good general education or equivalent standard

Desirable

• Medical Terminology qualifications

Experience

Essential

• Proficient IT skills
• Ability to accurately analyse and
• extract relevant information and pay
• attention to details
• Ability to absorb complex training and
• knowledge base
• Ability to work under pressure
• Ability to prioritise workload
• Able to communicate clearly and
• precisely (oral and written)
• Able to work in a team
• Ability to work under own initiative
• Willing to receive and absorb
• training
• Flexible approach to work

Desirable

• Knowledge of EMIS Web or
• System One
• Familiarity with clinical
• terminology
• Familiarity with read code
• hierarchy
• note summarising
• scanning/coding

Employer details

Employer name

East Lancashire Alliance

Address

Burnley Business Centre

Empire Way

Burnley

BB12 6HH

Employer's website

https://eastlancashirealliance.co.uk/ (Opens in a new tab)