Job summary
Reliable accurate and up to date coding of information is needed to support the running of the Trust and to meet the needs of commissioners and the Department of Health.This is achieved by the accurate translation of complex diagnostic and procedural information contained within Careflow into codes using national and international clinical coding classifications and entering the coded data onto Medicode.
A significant part of this role will be to ensure the quality and coverage of coding is constantly monitored and improved, to produce consistent, accurate, complete and timely coded clinical data in accordance with all national standards, local coding policies and commissioner deadlines. The post holder will be required to consistently deliver against demanding deadlines and be accountable for maintaining accuracy and compliance with frequently changing national standards and coding conventions.
The role requires excellent knowledge and understanding of medical terminology, human anatomy and physiology to aid accurate clinical coding across all specialties. The post holder will be working to challenging and tight deadlines, both individually and as a team.
Key working relationships with:-
Finance Department, Information Department, IT Department, Clinicians, other medical and nursing staff, ward staff and Healthcare Records staff.
Main duties of the job
- To extract relevant information from the electronic patient record to enable the coding of clinical activity.
- To critically analyse the data from all available sources relevant to the episode of care and interpret this information using the current classifications (World Health Organisation ICD10 and Office of Population Censuses and Surveys version 4.10), applying national and international rules and conventions whilst maintaining accuracy and completeness of coding. This will require the use of initiative and judgment to reconcile the given diagnoses and to integrate new procedures.
- To be responsible for accurate completion of all in patient and day case episodes ensuring that all relevant information is coded.
- To take responsibility for entering the coded clinical information onto Medicode.
- To identify missing activity for all specialities by producing daily/weekly lists of uncoded activity, using the information available from Careflow, discharge summaries, x-ray reports and histology reports.
- To report any discrepancies in data provision to the relevant Ward/Department and the Clinical Coding Manager
- To check and amend coded data regarding patient episodes on Medicode ensuring that all the information is accurate and complete.
- To develop and maintain good links with clinical staff
- To perform audits of coded data
- To act as a mentor to inexperienced coders and assist them in gaining specialised knowledge
About us
The Robert Jones and Agnes Hunt Orthopaedic NHS Trust (RJAH)is one of the leading orthopaedic hospitals in the country, with some of the highest levels of staff and patient satisfaction, as well as a strong reputation for research and innovation.
In the National Staff Survey, 74% of our staff would recommend the Trust as a place to work and 92% would recommend the hospital to a friend or relative for treatment.
Joining RJAH is more than just a job - we want our people to have the best opportunities to thrive in their role.We have a range of fantastic staff benefits on offer to everyone who joins RJAH and you'll have access to outstanding professional development opportunities and state-of-the-art facilities - including our recently-opened £6 million Headley Court Veterans' Orthopaedic Centre (the first unit of its kind in the UK).RJAH has strong links with a range of universities including Staffordshire, Keele, Glyndwr, Chester and Birmingham.The hospital is located on a site outside Oswestry in Oswestry, just off the A5. The nearest train station is in Gobowen, approximately two miles from the hospital. The station is part of the Chester to Birmingham line.We are based in North Shropshire, close to the border with North and Mid Wales. It is one of the most attractive parts of the country, with a rich historic culture and excellent transport links. It offers outstanding opportunities for anyone who enjoys an outdoor lifestyle or is looking to raise a family.
Job description
Job responsibilities
- To extract relevant information from the electronic patient record to enable the coding of clinical activity.
- To critically analyse the data from all available sources relevant to the episode of care and interpret this information using the current classifications (World Health Organisation ICD10 and Office of Population Censuses and Surveys version 4.10), applying national and international rules and conventions whilst maintaining accuracy and completeness of coding. This will require the use of initiative and judgment to reconcile the given diagnoses and to integrate new procedures.
- To be responsible for accurate completion of all in patient and day case episodes ensuring that all relevant information is coded.
- To be responsible for meeting existing targets of completed coding at month end.
- To take responsibility for entering the coded clinical information onto Medicode.
- To identify missing activity for all specialities by producing daily/weekly lists of uncoded activity, using the information available from Careflow, discharge summaries, x-ray reports and histology reports.
- To report any discrepancies in data provision to the relevant Ward/Department and the Clinical Coding Manager
- To check and amend coded data regarding patient episodes on Medicode ensuring that all the information is accurate and complete.
- To develop and maintain good links with clinical staff to improve and ensure good quality and depth of clinical coded data, amending clinical coding where necessary with particular reference to new treatments and procedures.
- To perform audits of coded data
- To act as a mentor to inexperienced coders and assist them in gaining specialised knowledge
- Supervise the clinical coding sub team and provide day to day management of the sub team
- Liaise with clinical staff for the sub specialties in their area, analysing complex data to ensure correct code assignment. Using own initiative to engage with Surgeons and clinical staff to review coding on a monthly basis.
- To have certified attendance at the NHS 21 day Clinical Coding Standards Course.
- To take responsibility for maintenance and improvements of clinical coding knowledge by attendance at the mandatory external NHS three yearly Refresher Training Course and other speciality courses in line with Department training plans.
- To assist with the preparation of DSPT
- To assist with the development of local coding policies following discussions with Clinicians.
- To be responsible for identifying personal training and development needs through appraisals in line with Trust policies.
- To provide codes to the Information Department to enable data analysis for statistical and research purposes.
- To provide coding information to other Departments within the Trust as and when required.
- To provide support and cover as required within the department
- To attend meetings as requested within own remit.
- To promote the professional image of the Clinical Coding Department throughout the Trust and to ensure that all duties are carried out in a professional manner.
- To main confidentiality at all times in line with the Data Protection Act.
Job description
Job responsibilities
- To extract relevant information from the electronic patient record to enable the coding of clinical activity.
- To critically analyse the data from all available sources relevant to the episode of care and interpret this information using the current classifications (World Health Organisation ICD10 and Office of Population Censuses and Surveys version 4.10), applying national and international rules and conventions whilst maintaining accuracy and completeness of coding. This will require the use of initiative and judgment to reconcile the given diagnoses and to integrate new procedures.
- To be responsible for accurate completion of all in patient and day case episodes ensuring that all relevant information is coded.
- To be responsible for meeting existing targets of completed coding at month end.
- To take responsibility for entering the coded clinical information onto Medicode.
- To identify missing activity for all specialities by producing daily/weekly lists of uncoded activity, using the information available from Careflow, discharge summaries, x-ray reports and histology reports.
- To report any discrepancies in data provision to the relevant Ward/Department and the Clinical Coding Manager
- To check and amend coded data regarding patient episodes on Medicode ensuring that all the information is accurate and complete.
- To develop and maintain good links with clinical staff to improve and ensure good quality and depth of clinical coded data, amending clinical coding where necessary with particular reference to new treatments and procedures.
- To perform audits of coded data
- To act as a mentor to inexperienced coders and assist them in gaining specialised knowledge
- Supervise the clinical coding sub team and provide day to day management of the sub team
- Liaise with clinical staff for the sub specialties in their area, analysing complex data to ensure correct code assignment. Using own initiative to engage with Surgeons and clinical staff to review coding on a monthly basis.
- To have certified attendance at the NHS 21 day Clinical Coding Standards Course.
- To take responsibility for maintenance and improvements of clinical coding knowledge by attendance at the mandatory external NHS three yearly Refresher Training Course and other speciality courses in line with Department training plans.
- To assist with the preparation of DSPT
- To assist with the development of local coding policies following discussions with Clinicians.
- To be responsible for identifying personal training and development needs through appraisals in line with Trust policies.
- To provide codes to the Information Department to enable data analysis for statistical and research purposes.
- To provide coding information to other Departments within the Trust as and when required.
- To provide support and cover as required within the department
- To attend meetings as requested within own remit.
- To promote the professional image of the Clinical Coding Department throughout the Trust and to ensure that all duties are carried out in a professional manner.
- To main confidentiality at all times in line with the Data Protection Act.
Person Specification
Qualifications
Essential
- 5 GCSE's A-C (or Equivalent) Including Maths, English and Science
- ECDL or Equivalent IT qualification or experience
- Completed clinical coding standards course and refresher course
- Accredited clinical coding qualification or equivalent experience (minimum 5 years)
Desirable
- Medical secretary training
Experience
Essential
- Experience of working in an NHS/Medical office environment
- Knowledge of computer systems / use of EPR or other hospital systems
Desirable
- Experience of working in an NHS clinical coding team
Skills
Essential
- Able to display attention to detail, maintaining high accuracy under pressure
- Able to work on own initiative - prioritise and organise own workload
- Specialist knowledge of medical terminology, anatomy and physiology
- Specialist knowledge of ICD10 and OPCS4 coding classifications and standards in the NHS environment
- Able to work with a range of professionals
- Ability to interpret information and to present information to diverse groups across the trust
- Excellent communication skills - verbal and written
- Team player
Desirable
- Experience of mentoring staff
Person Specification
Qualifications
Essential
- 5 GCSE's A-C (or Equivalent) Including Maths, English and Science
- ECDL or Equivalent IT qualification or experience
- Completed clinical coding standards course and refresher course
- Accredited clinical coding qualification or equivalent experience (minimum 5 years)
Desirable
- Medical secretary training
Experience
Essential
- Experience of working in an NHS/Medical office environment
- Knowledge of computer systems / use of EPR or other hospital systems
Desirable
- Experience of working in an NHS clinical coding team
Skills
Essential
- Able to display attention to detail, maintaining high accuracy under pressure
- Able to work on own initiative - prioritise and organise own workload
- Specialist knowledge of medical terminology, anatomy and physiology
- Specialist knowledge of ICD10 and OPCS4 coding classifications and standards in the NHS environment
- Able to work with a range of professionals
- Ability to interpret information and to present information to diverse groups across the trust
- Excellent communication skills - verbal and written
- Team player
Desirable
- Experience of mentoring staff
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.
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).
Additional information
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.
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).
