Responsibilities
* Responsible for abstraction, analysis and interpretation of complex clinical data from patient records, and assign the correct codes when conflicting information is present.
* Translate and assign accurate clinical codes for diagnosis, co‑morbidities and procedures for all discharged and transferred patients.
* Ensure strict adherence to coding procedures as established for clinical coding, taking into account changes to classifications as required.
* Participate in regular training sessions to develop and enhance coding specialty skills.
* Update national classification books and manuals in line with NHS Classification Service standards.
* Conduct bi‑monthly audits of completed work with a Lead Auditor, monitor and provide feedback on accuracy, completeness, compliance with national standards, and the quality of information recorded in health records to meet Trust targets.
* Demonstrate high skill in the use of ICD‑10 and OPCS‑4 classifications.
* Supervise and mentor trainee clinical coders in conjunction with Coding Managers or Training Manager, bringing them up to competence and monitoring incomplete episode reports.
* Be part of the senior coder pool that codes deceased patients.
* Identify and report errors in the Patient Administration System (e.g., incorrect consultant designation).
* Work with specialty divisions to support and maintain a professional, flexible coding service, capable of coding all specialties at a high level of accuracy and rotating as required with appropriate support and training.
* Provide specialist advice to clinical and non‑clinical staff regarding clinical coding.
* Ensure that working processes are followed in own area, initiate service reviews when processes are no longer effective, suggest development, and implement agreed revisions.
* Provide cover for absence of clinical coding staff, ensuring continuity of service provision.
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