Job summary
You will need to demonstrate a high level of clinical coding skill and the ability to work to a high degree of accuracy with attention to detail. You must be self-motivated able to work well under pressure and be flexible in your approach and you must be able to work well as part of a team working to tight deadlines.
You should have a good understanding of medical terminology, anatomy, and physiology. Good IT skills are also necessary as are good communication skills, It will be expected you will provide a vital and dynamic coding role within an excellent, high achieving and supportive coding team.
Further information refer Job Description.
Main duties of the job
- To abstract from the patients casenotes, and other sources as required, all relevant information concerning the primary diagnosis, co-morbidities, procedures, investigations, and treatment for each period of care.
- To translate this information into ICD-10 and OPCS 4 codes using judgement based on knowledge and experience and enter onto the hospital Patient Administration system, in a timely and accurate manner following the rules of coding convention for International Classification of Diseases and OPCS procedure books.
- Able to deal with coding queries and liaise with clinicians and specialty administration staff.
About us
Here at Portsmouth Hospitals University NHS Trust, we are proud to provide expert, compassionate care for our local population. We are ranked as the third in the country for research, embedding education and training across the organisation. Our main hub is the Queen Alexandra Hospital, which is one of the largest hospitals on the south coast employing over 8,700 staff.
Our patients come from all walks of life and so do we. We hire great people from a wide variety of backgrounds because it makes our hospital stronger. If you share our values and our enthusiasm for getting it right for patients, colleagues, and our community, you will find a home at Portsmouth Hospitals University NHS Trust
Job description
Job responsibilities
- To accurately extract and evaluate all relevant information concerning a patients episode of care involving identifying and interpreting often very complex clinical data detailing principal diagnosis and procedures, and any co-morbidities/complications and co- existing systemic conditions. This information is located in paper clinical record and various electronic systems.
- To translate this information into codes using ICD10 (International Classification of Diseases vol 10) and OPCS 4 (Office of Population Censuses and Surveys vol 4.8 which is then processed to create HRGS (Health Resource Groups) this is used to determine under the National tariff scheme the amount of funding the trust receives from the PCTS.
- Apply the rules and conventions of ICD10 and OPCS4 and take responsibility for updating training manuals and publications when changes or clarifications issued by the NHSIA. Inform the Coding supervisors of any national and/or local coding changes in order that they may be documented in manuals and the Coding Policy and Procedures
- To ensure all coded information extracted from provider spells/casenotes is accurate and reflects the full extent off all diagnosis and procedures that are provided by the clinician for every patient episode within an agreed time from patient discharge which supports the requirements of commissioning. Regular use of clinical coding reminder lists, and information systems are to be used to assist this process.
- Maintain level of accuracy within the complex specialties at PHU required for experienced Clinical coder by attending specialist workshops, refresher training and working to HSCIC standards.
- To maintain a comprehensive knowledge of anatomy and physiology, medical procedures, diagnosis, and terminology as applied across specialties.
- Establish a liaison with clinicians and specialty administration staff to ensure clinically relevant information is available to support the highest quality clinical coding, including the communication of complex clinical coding rules to relevant parties. To liaise with health records staff on all clerical aspects of casenote requests and tracking and the tracing of lost casenotes.
- Managing own workload to maintain departmental standards of productivity and quality, ensure high quality clinical coding of complex clinical records from a wide variety of sources, and in all Trust specialties, to ensure an accurate and timely coded record of Trust clinical activity.
- Communicate complex coding rules to medical, clinical, administrative staff and external agencies to maximise recording of relevant clinical history and events, in order to accurately portray the clinical workload of the Trust and morbidity of admitted patients.
- Advise less experienced coders in the correct coding of clinical notes as required.
- To regularly review, and if necessary, revise work practices and information flows in conjunction with the Coding Manager, considering the needs of the Directorates, Trust, and NHS mandatory requirements. Any changes in local coding policies should be ratified by the clinician and be included in the Clinical Coding Policy and Procedures document.
- To be aware of the weekly list of incomplete episodes and liaise with the Coding clerk to ensure these are retrieved and coded.
- On completion of episodes use the Patient Administration System to identify any other incomplete episodes and to take the appropriate action to deal with them. The return of notes for completion of provider spells is to be in accordance with departmental procedures.
- Use the Medical Encoder for accessing clinical information for coding purposes and for passing completed coding details to the PAS system.
- Use the minestrone and Maternity System (badgernet) for accessing clinical information to clarify diagnosis for coding purposes.
- To ensure that the PAS system is updated with the correct information on location and destination of all received casenotes to ensure they are available if required using Casenote Tracking.
- To take responsibility for passing any coding queries via the Coding manager to the NHS centre for classification.
- Participate in pilot studies and special projects as required, be aware of new procedures introduced to the Trust for the purposes of clinical coding and assist in the accreditation and audit of data both internally and externally as required by the Trust policy of Clinical Governance.
- Participate in Individual Performance Review (IPR) and undertake identified training and development as agreed with the Coding Manager, including attending training courses, workshops, and conferences both internally and external as required.
- As part of the Trust Clinical Coding Team, provide cover for colleagues in times of annual leave or sickness absence to ensure continuity of work and also participate in induction and training of new team members.
- Carry out any other task consistent with grade and experience as determined by the Coding Manager, or other Senior Manager within the Corporate Division.
- Ensure effective team working with other members of the clinical directorates ensuring skills and knowledge are transferred as appropriate, whilst ensuring working procedures are properly documented and maintained.
- Take responsibility for ensuring patient information that you handle is always kept confidential, within a secure environment, and only referenced for the purpose of conducting your duties.
Job description
Job responsibilities
- To accurately extract and evaluate all relevant information concerning a patients episode of care involving identifying and interpreting often very complex clinical data detailing principal diagnosis and procedures, and any co-morbidities/complications and co- existing systemic conditions. This information is located in paper clinical record and various electronic systems.
- To translate this information into codes using ICD10 (International Classification of Diseases vol 10) and OPCS 4 (Office of Population Censuses and Surveys vol 4.8 which is then processed to create HRGS (Health Resource Groups) this is used to determine under the National tariff scheme the amount of funding the trust receives from the PCTS.
- Apply the rules and conventions of ICD10 and OPCS4 and take responsibility for updating training manuals and publications when changes or clarifications issued by the NHSIA. Inform the Coding supervisors of any national and/or local coding changes in order that they may be documented in manuals and the Coding Policy and Procedures
- To ensure all coded information extracted from provider spells/casenotes is accurate and reflects the full extent off all diagnosis and procedures that are provided by the clinician for every patient episode within an agreed time from patient discharge which supports the requirements of commissioning. Regular use of clinical coding reminder lists, and information systems are to be used to assist this process.
- Maintain level of accuracy within the complex specialties at PHU required for experienced Clinical coder by attending specialist workshops, refresher training and working to HSCIC standards.
- To maintain a comprehensive knowledge of anatomy and physiology, medical procedures, diagnosis, and terminology as applied across specialties.
- Establish a liaison with clinicians and specialty administration staff to ensure clinically relevant information is available to support the highest quality clinical coding, including the communication of complex clinical coding rules to relevant parties. To liaise with health records staff on all clerical aspects of casenote requests and tracking and the tracing of lost casenotes.
- Managing own workload to maintain departmental standards of productivity and quality, ensure high quality clinical coding of complex clinical records from a wide variety of sources, and in all Trust specialties, to ensure an accurate and timely coded record of Trust clinical activity.
- Communicate complex coding rules to medical, clinical, administrative staff and external agencies to maximise recording of relevant clinical history and events, in order to accurately portray the clinical workload of the Trust and morbidity of admitted patients.
- Advise less experienced coders in the correct coding of clinical notes as required.
- To regularly review, and if necessary, revise work practices and information flows in conjunction with the Coding Manager, considering the needs of the Directorates, Trust, and NHS mandatory requirements. Any changes in local coding policies should be ratified by the clinician and be included in the Clinical Coding Policy and Procedures document.
- To be aware of the weekly list of incomplete episodes and liaise with the Coding clerk to ensure these are retrieved and coded.
- On completion of episodes use the Patient Administration System to identify any other incomplete episodes and to take the appropriate action to deal with them. The return of notes for completion of provider spells is to be in accordance with departmental procedures.
- Use the Medical Encoder for accessing clinical information for coding purposes and for passing completed coding details to the PAS system.
- Use the minestrone and Maternity System (badgernet) for accessing clinical information to clarify diagnosis for coding purposes.
- To ensure that the PAS system is updated with the correct information on location and destination of all received casenotes to ensure they are available if required using Casenote Tracking.
- To take responsibility for passing any coding queries via the Coding manager to the NHS centre for classification.
- Participate in pilot studies and special projects as required, be aware of new procedures introduced to the Trust for the purposes of clinical coding and assist in the accreditation and audit of data both internally and externally as required by the Trust policy of Clinical Governance.
- Participate in Individual Performance Review (IPR) and undertake identified training and development as agreed with the Coding Manager, including attending training courses, workshops, and conferences both internally and external as required.
- As part of the Trust Clinical Coding Team, provide cover for colleagues in times of annual leave or sickness absence to ensure continuity of work and also participate in induction and training of new team members.
- Carry out any other task consistent with grade and experience as determined by the Coding Manager, or other Senior Manager within the Corporate Division.
- Ensure effective team working with other members of the clinical directorates ensuring skills and knowledge are transferred as appropriate, whilst ensuring working procedures are properly documented and maintained.
- Take responsibility for ensuring patient information that you handle is always kept confidential, within a secure environment, and only referenced for the purpose of conducting your duties.
Person Specification
Qualifications
Essential
- Educated to NVQ Level 4 or equivalent experience
Experience
Essential
- You should have a minimum of two years experience working in an acute NHS Trust covering all specialities
- Required to work towards achieving the Accredited Clinical Coder qualification.
Skills and Knowledge
Essential
- Excellent knowledge of the coding process assessed by a formal all speciality clinical coding audit achieving a minimum of 90% correct primary diagnosis and procedure, secondary diagnoses, and procedures
- Knowledge of medical terminology
- Good interpersonal and organisational skills
- Ability to work under pressure and to deadlines
- Computer literacy and keyboard skills
- Ability to think logically, analyse and interpret information
- Awareness of patient confidentiality
- Well-developed influencing skills
- A Test will be provided at interview (Medical anatomy and coding)
- Effective communicator (oral and written)
- Understanding of departmental aims
Person Specification
Qualifications
Essential
- Educated to NVQ Level 4 or equivalent experience
Experience
Essential
- You should have a minimum of two years experience working in an acute NHS Trust covering all specialities
- Required to work towards achieving the Accredited Clinical Coder qualification.
Skills and Knowledge
Essential
- Excellent knowledge of the coding process assessed by a formal all speciality clinical coding audit achieving a minimum of 90% correct primary diagnosis and procedure, secondary diagnoses, and procedures
- Knowledge of medical terminology
- Good interpersonal and organisational skills
- Ability to work under pressure and to deadlines
- Computer literacy and keyboard skills
- Ability to think logically, analyse and interpret information
- Awareness of patient confidentiality
- Well-developed influencing skills
- A Test will be provided at interview (Medical anatomy and coding)
- Effective communicator (oral and written)
- Understanding of departmental aims
Disclosure and Barring Service Check
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.
