Senior Coder

Job description

Job responsibilities

• Screen medical records, discharge summaries, histopathology results and other data sources to extract clinical information relevant to a patients episode of care.
• Through effective data extraction analyse complex clinical information; apply independent judgement in the interpretation, transposition and sequencing of clinical data adhering to national rules and conventions.
• Code all patient episodes using clinical terms computerised encoding system supported by International Classification of Diseases (ICD 10) and Office of the Population of Censuses and Surveys (OPCS 4) coding manuals.
• Exercise initiative in selecting appropriate clinical terms to accurately reflect the individual patient record.
• Ensure data is entered accurately into the Patient Administration System (PAS) within national defined timescales.
• Regularly required to access and read patient case notes where the content can be distressing.
• Develop and maintain skills to use the PAS system and adhere to local coding protocols/procedures.
• Check patient details held on the system are correct e.g. consultant, date of admission and discharge reporting any incorrect details to the Data Quality Team.
• Routinely run outstanding episode reports from the Patient Administration System and action by searching for missing source documentation.
• Code complex specialties including mortality coding.
• Maintain and update as necessary the relevant Coding Manuals and Coding Clinic updates following national direction.
• Professionally responsible for the coding team.
• Be a point of contact for coding and coding team related queries, taking action where appropriate.
• Provide cross site cover for the Clinical Coding Team during periods of absence.
• Participate in the audit of the accuracy and depth of Coding.
• Undertake delegated responsibilities and any other duties as requested from the supervisor/manager.

Communication:

• Prioritise and plan the daily and weekly work pattern for the Coding Team reporting any issues/concerns to the Clinical Coding Divisional Leads.
• Supervise the Clinical Coding Team(s) on a daily basis in the absence of the Clinical Coding Divisional Leads.
• Ability to deputise in the absence of the Divisional Lead to cover urgent issues.
• Demonstrate effective organisational and time management skills with the ability to work independently and as part of a team. Be highly motivated and lead by example to motivate other team members.
• Communicate and liaise effectively with clinicians, nursing staff, other professionals and departments, both internal and external, concerning routine or complex issues / anomalies across all specialties whilst maintaining good relationships.
• Actively seek source documentation i.e. discharge summary/case notes not routinely received by visiting wards, departments etc.
• Identify inadequate source documentation and communicate with relevant health care professionals to rectify this.
• Manage and resolve coding queries liaising with senior clinicians on a regular basis.
• Regularly attend and participate in multi-disciplinary team meetings providing expert coding advice.
• Participate in knowledge sharing sessions to be held across all sites for multiple specialties as identified by service requirement.
• Attend internal and external seminars as and when required. Participate in clinical coding awareness sessions and road shows for all levels of staff.

Training and Education:

• Responsible for the training and coaching of the Clinical Coding Team.
• Participate in the orientation, training and mentorship for less experienced coding officers providing advice and support.
• Remove or amend clinical codes to Finished Consultant Episodes (FCEs) as directed by the Clinical Coding Divisional Leads or Clinical Coding Auditor. Re-input clinical codes as necessary.
• Maintain coding skills by attending a refresher course every 2-3 years and specialty workshops where appropriate eg obstetrics, trauma and orthopaedics.
• Take responsibility for keeping up to date with current issues and developments within the coding department.
• Participate in creating an environment conducive to the acquisition of further knowledge and skills.
• To take every reasonable opportunity to maintain and improve your professional knowledge and competence.

Planning and Policy

• Through meeting personal objectives contribute to the broader objectives of the directorate relating to planning and performance improvement.
• Maintain an up to date knowledge of national and local clinical coding guidance and requirements,
• Implement and refer to the departments Clinical Coding Policy/Procedure Document for coding purposes.
• Document any local changes in coding processes/information flows for all specialties informing the Clinical Coding Divisional Leads prior to action being taken.
• Responsible for the management of a coding caseload working on own initiative and prioritising where appropriate to meet monthly deadlines.
• Ensure an organised work station to enable others to cover when absent.

Person Specification

Experience

• The principles of Clinical Coding.
• Significant knowledge of anatomy and physiology and medical terminology.
• Significant knowledge of clinical coding requirements and standards.

Personal Attributes

• Ability to work on own initiative to prioritise and plan workloads.
• Confident working remotely and troubleshooting any minor IT issues which may arise.
• Able to work accurately under pressure to meet deadlines.
• Effective and supportive Team player.
• A flexible approach to working hours.
• Ability to maintain and develop own skills and knowledge.
• Monitors own targets/performance.
• Self-motivated.
• Adaptable to change.
• Ability to manage difficult situations confidently.

Skills and Abilities

• Able to use Microsoft applications i.e. word, excel.
• Ability to correctly code a number of clinical specialties and more complex specialties.
• Ability to provide coding advice and support to less experienced coding officers.
• Ability to work to a high degree of accuracy and attention to detail.
• Ability to communicate with colleagues at different levels eg multi-disciplinary teams.
• Ability to explain complex coding terminology to a variety of contacts and stakeholders in order that they clearly understand coding requirements.
• Ability to overcome barriers to engagement with stakeholders using persuasive communications.

Qualifications

• National Clinical Coding Qualification.
• Minimum A level qualification or equivalent qualification or equivalent knowledge.
• Undertaken the Clinical Coding Standards Course.
• Up to date with Clinical Coding Refresher Courses.
• Pass a coder audit.

• Qualification or experience in science or healthcare environment.
• European Computer Driving Licence (ECDL).

Certificate of Sponsorship

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.

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.

Employer details

Employer name

The Mid Yorkshire Teaching NHS Trust

Address

Pinderfields Hospital

Aberford Road

Wakefield

West Yorkshire

WF1 4DG

https://www.midyorks.nhs.uk/