Job summary
We are currently seeking individuals to join a friendly team committed to providing a high quality clinical coding service to the Trust. As a clinical coder at this large teaching hospital you will have the opportunity to code a range of specialist services. The department has its own Terminology & Classifications Delivery Service Approved Trainer & Auditor and has offices at both the Royal Hallamshire and Northern General Hospitals.
To ensure that clinical information is accurately and efficiently extracted from patients case notes, translating this information into appropriate ICD & OPCS codes for subsequent entry onto statistical databases. The resulting information is used by the Trust for managing resources, clinical research and commissioning.
The ability to work as part of a wider team is important and having a desire to learn from and share knowledge with others is imperative.
None ACC Coders will be considered for employment on AfC Band 3
Main duties of the job
- Extracting clinical information from patient hospital records, records are both in both a digital and paper format. Determine the correct ICD and OPCS codes to reflect the patient clinical journey and through the utilisation of appropriate coding standards enter the codes into the Trusts coding platform.
- Engage with clinicians at all levels to clarify the content of source documentation where information is unclear.
- Participate in implementation of Trust policies and procedures.
- Participate in regular cross site departmental meeting in order to facilitate standardization of working practices and dissemination of information in respect of coding issues.
- Ensure that office equipment is in good working order and report any problems to the Clinical Coding Manager. Be responsible for maintaining an adequate supply of essential stationery for personal use.
About us
You will be working for an organisation which values and respects all of its staff and the community it serves. The Trust is a leader in the NHS and research sectors and provides excellent benefits for its staff. This includes commitments to professional development but also many policies to support employees in balancing their personal and professional lives.
Clinical Data Capture offers flexible working which can incorporate some weekend & home working.
Please also note this vacancy is a training post so all applicants will start at Band 3 and upon completion of necessary skills and/ or training will progress to Band 4
Job description
Job responsibilities
- Extract clinical information from case notes in order to identify both diagnoses and procedures. This will involve using own judgement in order to assign primary and secondary status in complex cases or where there are several episodes of care within a hospital stay. It is necessary to read through detailed case histories in order to ensure completeness and accuracy of data and this will often involve exposure to potentially distressing/disturbing information/photographs.
- Translate clinical information into appropriate codes using national coding classifications. This requires an in depth knowledge of coding procedures and conventions and the acquisition of medical terminology. An awareness of human anatomy and physiological terms is also necessary. The performance of these tasks requires a high level of concentration in order to ensure the accuracy of this vital data.
- Prioritise the clinical codes according to the rules and conventions laid down by the World Health Organisation and the Clinical Classifications service. This will require the application of analytical and judgemental skills on a regular basis.
- Where necessary liaise with clinicians to clarify coding queries where the information provided is inadequate/insufficient to enable correct assignment off codes.
- Frequent daily use of multiple computer systems to extract, input, validate and update data and request printouts. This requires a high level of concentration as any inaccuracies could have financial and reputation implications for the Trust.
- Deal with telephone enquires from administrative, medical and clinical staff in respect of clinical coding queries.
- Participate in regular meetings with clinicians/managers in order to promote and maintain a good working relationship and provide regular two way communication in order to resolve coding queries.
- Assist with the training of new staff in the department by providing information on how tasks should be performed and giving examples of good working practice.
- Maintain confidentiality in all areas and at all times.
- Ensure Health and Safety procedures are adhered to. Participate in Health and Safety assessments and monitoring.
Job description
Job responsibilities
- Extract clinical information from case notes in order to identify both diagnoses and procedures. This will involve using own judgement in order to assign primary and secondary status in complex cases or where there are several episodes of care within a hospital stay. It is necessary to read through detailed case histories in order to ensure completeness and accuracy of data and this will often involve exposure to potentially distressing/disturbing information/photographs.
- Translate clinical information into appropriate codes using national coding classifications. This requires an in depth knowledge of coding procedures and conventions and the acquisition of medical terminology. An awareness of human anatomy and physiological terms is also necessary. The performance of these tasks requires a high level of concentration in order to ensure the accuracy of this vital data.
- Prioritise the clinical codes according to the rules and conventions laid down by the World Health Organisation and the Clinical Classifications service. This will require the application of analytical and judgemental skills on a regular basis.
- Where necessary liaise with clinicians to clarify coding queries where the information provided is inadequate/insufficient to enable correct assignment off codes.
- Frequent daily use of multiple computer systems to extract, input, validate and update data and request printouts. This requires a high level of concentration as any inaccuracies could have financial and reputation implications for the Trust.
- Deal with telephone enquires from administrative, medical and clinical staff in respect of clinical coding queries.
- Participate in regular meetings with clinicians/managers in order to promote and maintain a good working relationship and provide regular two way communication in order to resolve coding queries.
- Assist with the training of new staff in the department by providing information on how tasks should be performed and giving examples of good working practice.
- Maintain confidentiality in all areas and at all times.
- Ensure Health and Safety procedures are adhered to. Participate in Health and Safety assessments and monitoring.
Person Specification
Qualification
Essential
- Clinical Coding Standards Course Pass
- Clinical Coding refresher training if standards course pass over 3 years previous
- Clinical Coding Standards Course or Clinical Coding refresher training within last 2-3 years (Band 4)
- Accredited Clinical Coder (Band 4)
Desirable
- Qualifications at A level or equivalent
- GCSE level C or above biology / science
- Medical terminology
- Knowledge of anatomy and physiology
Further Training
Desirable
- Speciality Clinical Coding workshops (Band 4)
Experience
Essential
- Ability to extract relevant information from data
- Computer literacy with accurate keyboard skills
- Experience of using ICD-10 and OPCS 4.9 Coding Manuals
- Ability to locate and utilise coding standards relevant to the extracted data
- Recent significant coding experience in the UK, including the ability to code across a variety of specialties. (Band 4)
- A demonstrated awareness of modern clinical coding practice and issues (Band 4)
Desirable
- Recent use of a hospital PAS
- Use of encoding software
- Use of other hospital clinical information systems or EPR
- Acute NHS Trust coding experience
- Previous Mentoring role. (Band 4)
Special Skills/Aptitudes
Essential
- Neat methodical working procedures
- Inquisitive
- Attention to detail
- Good communication skills, verbal and written
- Able to apply clinical codes to a variety clinical specialities to a minimum accuracy level of 80%
- Time management skills / prioritisation (Band 4)
- Mentoring ability (Band 4)
Desirable
Other Factors
Essential
- Able to work well within a team and be flexible in working practices
- A willingness to learn from and share knowledge with others
- Ability to work under pressure whilst maintaining accuracy
- Understanding of patient confidentiality
- Demonstrates and upholds the Trust PROUD values
- Commitment to work towards accredited clinical coder status
- Lifelong learning commitment
Person Specification
Qualification
Essential
- Clinical Coding Standards Course Pass
- Clinical Coding refresher training if standards course pass over 3 years previous
- Clinical Coding Standards Course or Clinical Coding refresher training within last 2-3 years (Band 4)
- Accredited Clinical Coder (Band 4)
Desirable
- Qualifications at A level or equivalent
- GCSE level C or above biology / science
- Medical terminology
- Knowledge of anatomy and physiology
Further Training
Desirable
- Speciality Clinical Coding workshops (Band 4)
Experience
Essential
- Ability to extract relevant information from data
- Computer literacy with accurate keyboard skills
- Experience of using ICD-10 and OPCS 4.9 Coding Manuals
- Ability to locate and utilise coding standards relevant to the extracted data
- Recent significant coding experience in the UK, including the ability to code across a variety of specialties. (Band 4)
- A demonstrated awareness of modern clinical coding practice and issues (Band 4)
Desirable
- Recent use of a hospital PAS
- Use of encoding software
- Use of other hospital clinical information systems or EPR
- Acute NHS Trust coding experience
- Previous Mentoring role. (Band 4)
Special Skills/Aptitudes
Essential
- Neat methodical working procedures
- Inquisitive
- Attention to detail
- Good communication skills, verbal and written
- Able to apply clinical codes to a variety clinical specialities to a minimum accuracy level of 80%
- Time management skills / prioritisation (Band 4)
- Mentoring ability (Band 4)
Desirable
Other Factors
Essential
- Able to work well within a team and be flexible in working practices
- A willingness to learn from and share knowledge with others
- Ability to work under pressure whilst maintaining accuracy
- Understanding of patient confidentiality
- Demonstrates and upholds the Trust PROUD values
- Commitment to work towards accredited clinical coder status
- Lifelong learning commitment
Additional information
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
