Job summary
We are looking to appoint two experienced and enthusiastic ACC Clinical Coders to join our friendly and professional team at Great Western Hospital Foundation NHS Trust as Divisional Lead Clinical Coders.
It's an exciting time for our growing department and the successful candidates will provide clinical coding expertise and knowledge to the team, as well as establishing interdepartmental channels and increased clinical engagement between Clinical Coding and the Divisions of Medicine, and Surgery, Women's & Children.
*Subject to job evaluation*
Main duties of the job
Abstract and analyse relevant complex clinical information patient notes and the Trust's electronic systems to assign accurate diagnostic, intervention and procedure codes using ICD10/OPCS-4 classifications, following and in keeping with the well-defined national coding standards. This will involve making judgements on complex facts requiring interpretation and comparing options from information provided electronically and in paper notes.
Responsible for consulting with clinicians and clinical directors in the Divisions of Medicine, and Surgery, Women, and Children's to enhance the accuracy and depth of the clinical coding within these areas.
Provide support to the Clinical Coding Audit manager in highlighting areas for review and implementing necessary changes following audit feedback.
Provide support to Clinical Coding Trainer by implementing and suggesting training opportunities for the coding team, paying particular attention to the applicable division.
About us
You will be joining a growing department which places emphasis on professional and personal development.
These new posts will be at the forefront of our drive to deliver a comprehensive, accurate clinical coding service to the Trust.
We can offer flexible working, to include remote working. Clinical coders currently have the option to work from home 3 days each week.
We are currently embedding a continuous improvement methodology we callImproving Togetherinto our organisation and are equipping all of our staff with the training and support to turn their great ideas into reality.
That will help us to deliver an even better level of patient care, but we know that we need an improved estate to offer quality care too. That is why we have a large site development plan underway, called our'Way Forward Programme', which seeks to develop a more integrated, streamlined and efficient health care system that will provide an effective balance of urgent and longer term care for patients' best interests.
There has never been a better or more exciting time to join our organisation, and the opportunities for you are limitless.
Our Values
Our Star Values are the golden thread running through everything we do and help us to deliver our vision of providing great, joined up services for the community. You can expect to see our values in the way we act and the way we treat each other. Our values make us who we are.
Service-We will put our patients first
Teamwork-We will work together
Ambition-We will aspire to provide the best service
Respect-We will act with integrity
Job description
Job responsibilities
Accurately abstract and analyse patient clinical records, to extract all relevant diagnoses, complications, co-morbidities and any procedures relevant to the selected inpatient spell.
Using ICD-10 (International Classification of Diseases), and OPCS (Office of Population Census & Surveys) reference books, assign accurate codes for primary & secondary diagnoses and any procedures conducted, adhering to national coding conventions and procedures as defined by the World Health Organisation (WHO) and NHS Digital (the Health and Social Care Information Centre).
Maintain Clinical Coding accuracy for quality (90%+) and rate of coding (minimum 4 FCEs per hour) to produce high quality timely data for the Trust.
Use clinical coding expertise to communicate complex coding rules to consultants, other medical and administrative staff, and confidently discuss the rationale which leads to the codes that have been chosen. Consult with clinicians for clarification on new interventional procedures and clinical practice to ensure correct understanding for code assignment.
Pro-actively engage with and assist clinicians within the applicable division to provide expert advice on coding issues.
Produce reports for clinicians within the applicable division highlighting areas where coding could be improved and work with clinicians to improve the level of clinical documentation required and available to coders.
Attend directorate meetings to provide clinical coding perspective and awareness, communicating complex coding rules and ensuring that coding will be accurate along with the income generated.
Identify areas within the division that would benefit from coding validation by benchmark analysis against other trusts/regions.
Develop and deliver training sessions to clinicians and directorate staff when requested, to improve the knowledge and importance of clinical coding across the trust.
Working with the senior coding team, develop a programme for clinicians to validate their data to ensure compliance with coding standards and improve documentation available to coding team.
Work closely with and support the Clinical Coding Audit manager, reviewing areas of concern within the applicable division and feed back to colleagues changes in coding guidance and improvements to be made.
Work closely with the Clinical Coding Trainer to identify areas of coding that the team need further guidance and training on and provide support in delivering training sessions and objectives to the team.
Plan and manage own workload daily, working towards agreed objectives and with autonomy of how they will be achieved.
Play a key role in ensuring monthly clinical coding deadlines are met. Contribute to the provision of assistance to other staff within the department with the responsibility for covering the work of colleagues during the periods of absence or peak workloads.
Generate reports to identify patients for whom coding has not been completed. Monitor any coding backlog and ensure the backlog is managed and actioned in a structured manner. Visit wards and other clinical areas, as required, to retrieve the clinical records for these patients and complete the coding by referring to the clinical history, within agreed Trust deadlines.
Use the patient administration system and other clinical systems to obtain diagnostic and procedural information. Access radiology and pathology results to update coded information not defined at procedure or discharge. Apply knowledge of clinical terminology, anatomical and physiological terms as necessary to amend coding to reflect these results.
Ensured own coding data is entered onto the patient administration system in an accurate and timely manner. As part of the coding process, ensure that the admission, transfer, and discharge data for each inpatient episode is correct. Inform the patient administration system management team when a patients inpatient activity has been missed or incorrectly entered to ensure the patient administration system is updated or corrected to produce accurate data capture.
Be responsible for ensuring own clinical coding skills are maintained and are compliant with all published updates to National Standard requirements and through completing the mandatory national Clinical Coding Refresher course every 3 years. Actively contribute to and participate in internal coding review sessions.
Use clinical coding expertise to respond to coding queries from Information Services for reporting, and Freedom of Information requests plus other requests from staff throughout the Trust regarding diagnosis and procedure codes.
Assist the Clinical Coding Team Manager to develop an improved communication system between the Clinical Coding Department and Clinicians and other Medical Professionals to ensure they understand the coding process (and its limitations) and proactively identify/deliver opportunities to improve the coding process.
Assisting in the development of local coding policies and procedures
Deputise for the Clinical Coding Team Manager during periods of absence, to ensure the continued day to day smooth running of the coding process within the Clinical Coding Team
Job description
Job responsibilities
Accurately abstract and analyse patient clinical records, to extract all relevant diagnoses, complications, co-morbidities and any procedures relevant to the selected inpatient spell.
Using ICD-10 (International Classification of Diseases), and OPCS (Office of Population Census & Surveys) reference books, assign accurate codes for primary & secondary diagnoses and any procedures conducted, adhering to national coding conventions and procedures as defined by the World Health Organisation (WHO) and NHS Digital (the Health and Social Care Information Centre).
Maintain Clinical Coding accuracy for quality (90%+) and rate of coding (minimum 4 FCEs per hour) to produce high quality timely data for the Trust.
Use clinical coding expertise to communicate complex coding rules to consultants, other medical and administrative staff, and confidently discuss the rationale which leads to the codes that have been chosen. Consult with clinicians for clarification on new interventional procedures and clinical practice to ensure correct understanding for code assignment.
Pro-actively engage with and assist clinicians within the applicable division to provide expert advice on coding issues.
Produce reports for clinicians within the applicable division highlighting areas where coding could be improved and work with clinicians to improve the level of clinical documentation required and available to coders.
Attend directorate meetings to provide clinical coding perspective and awareness, communicating complex coding rules and ensuring that coding will be accurate along with the income generated.
Identify areas within the division that would benefit from coding validation by benchmark analysis against other trusts/regions.
Develop and deliver training sessions to clinicians and directorate staff when requested, to improve the knowledge and importance of clinical coding across the trust.
Working with the senior coding team, develop a programme for clinicians to validate their data to ensure compliance with coding standards and improve documentation available to coding team.
Work closely with and support the Clinical Coding Audit manager, reviewing areas of concern within the applicable division and feed back to colleagues changes in coding guidance and improvements to be made.
Work closely with the Clinical Coding Trainer to identify areas of coding that the team need further guidance and training on and provide support in delivering training sessions and objectives to the team.
Plan and manage own workload daily, working towards agreed objectives and with autonomy of how they will be achieved.
Play a key role in ensuring monthly clinical coding deadlines are met. Contribute to the provision of assistance to other staff within the department with the responsibility for covering the work of colleagues during the periods of absence or peak workloads.
Generate reports to identify patients for whom coding has not been completed. Monitor any coding backlog and ensure the backlog is managed and actioned in a structured manner. Visit wards and other clinical areas, as required, to retrieve the clinical records for these patients and complete the coding by referring to the clinical history, within agreed Trust deadlines.
Use the patient administration system and other clinical systems to obtain diagnostic and procedural information. Access radiology and pathology results to update coded information not defined at procedure or discharge. Apply knowledge of clinical terminology, anatomical and physiological terms as necessary to amend coding to reflect these results.
Ensured own coding data is entered onto the patient administration system in an accurate and timely manner. As part of the coding process, ensure that the admission, transfer, and discharge data for each inpatient episode is correct. Inform the patient administration system management team when a patients inpatient activity has been missed or incorrectly entered to ensure the patient administration system is updated or corrected to produce accurate data capture.
Be responsible for ensuring own clinical coding skills are maintained and are compliant with all published updates to National Standard requirements and through completing the mandatory national Clinical Coding Refresher course every 3 years. Actively contribute to and participate in internal coding review sessions.
Use clinical coding expertise to respond to coding queries from Information Services for reporting, and Freedom of Information requests plus other requests from staff throughout the Trust regarding diagnosis and procedure codes.
Assist the Clinical Coding Team Manager to develop an improved communication system between the Clinical Coding Department and Clinicians and other Medical Professionals to ensure they understand the coding process (and its limitations) and proactively identify/deliver opportunities to improve the coding process.
Assisting in the development of local coding policies and procedures
Deputise for the Clinical Coding Team Manager during periods of absence, to ensure the continued day to day smooth running of the coding process within the Clinical Coding Team
Person Specification
Qualifications
Essential
- Degree or equivalent training and experience
- NHS Accredited Clinical Coder Qualification
- CCCS Clinical Coding Refresher Training Course Certification
Desirable
- Anatomy & Physiology or Human Biology qualification
- NHS Digital Clinical Coding workshops or specialty courses
Experience
Essential
- At least 3 years of demonstrable experience of coding inpatient activity across a wide range of specialties within an acute NHS Trust setting
- Significant knowledge, experience and understanding of ICD10 & OPCS4 coding classifications and standards applicable to NHS inpatient activity
- Considerable experience of using paper and electronic records to extract clinical information
- Collaborating with clinicians and senior managers around clinical engagement and education
Desirable
- Experience of undertaking clinical coding audits and presenting reports
- Experience in developing and mentoring trainee coding staff
- Experience in the preparation and delivery of presentations to a group of people
Knowledge and skills
Essential
- Excellent communication, both verbal and written
- Good IT skills, experience using Microsoft applications
- Proven ability to abstract & analyse complex clinical information
- Significant understanding of medical terminology and anatomy & physiology
- Good understanding of the importance of clinical coding and its uses and the impact of data issues
- Understanding of Information Governance and Confidentiality
- A good understanding of the relevance of coded data in context of HRGs and PbR
Person Specification
Qualifications
Essential
- Degree or equivalent training and experience
- NHS Accredited Clinical Coder Qualification
- CCCS Clinical Coding Refresher Training Course Certification
Desirable
- Anatomy & Physiology or Human Biology qualification
- NHS Digital Clinical Coding workshops or specialty courses
Experience
Essential
- At least 3 years of demonstrable experience of coding inpatient activity across a wide range of specialties within an acute NHS Trust setting
- Significant knowledge, experience and understanding of ICD10 & OPCS4 coding classifications and standards applicable to NHS inpatient activity
- Considerable experience of using paper and electronic records to extract clinical information
- Collaborating with clinicians and senior managers around clinical engagement and education
Desirable
- Experience of undertaking clinical coding audits and presenting reports
- Experience in developing and mentoring trainee coding staff
- Experience in the preparation and delivery of presentations to a group of people
Knowledge and skills
Essential
- Excellent communication, both verbal and written
- Good IT skills, experience using Microsoft applications
- Proven ability to abstract & analyse complex clinical information
- Significant understanding of medical terminology and anatomy & physiology
- Good understanding of the importance of clinical coding and its uses and the impact of data issues
- Understanding of Information Governance and Confidentiality
- A good understanding of the relevance of coded data in context of HRGs and PbR
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).
