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Senior clinical coder

Wakefield
Permanent
Mid Yorkshire Teaching NHS Trust
Posted: 1 October
Offer description

Contact information

Kerry Reynolds, Clinical Coding Divisional Lead would be very pleased to discuss your application further or any questions you may have. You may contact Kerry via telephone number 01924 543935 / 07860686933 or email kerry.reynolds5@nhs.net

About the role

The Clinical Coding Department is responsible for the accurate and timely recording of clinical data to support the Trust’s clinical and business requirements and for regional and National Health Service statistics.

Our Trust recognises the vital contribution of our coding team to our overall Trust performance and regards our team as pivotal to our future performance.

The post holder will be required to work as a member of a team to provide an efficient clinical coding service working to established systems and procedures.

To screen medical records, discharge summaries and other data sources to extract clinical information relevant to a patient’s episode of care.

Through effective data extraction analyse complex clinical information; apply independent judgement in the interpretation, translation and sequencing of clinical data adhering to national rules and conventions.

To code all patient episodes using the M360 Solventum encoding system supported by International Classification of Diseases (ICD 10) and Office of the Population of Census and Surveys (OPCS 4) coding classifications.

Ensure data is entered accurately into the Patient Administration System within nationally/locally defined timescales.

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.

As a member of our team, you will work as part of a well-structured team, who are fully committed to your personal development. The team has the support of a Coding Auditor, Coding Trainers, and Divisional Leads.

To reflect the high regard the coding team are held, all staff will join a supportive and professional career structure from Trainee Coder to Divisional Lead level. Full ongoing training and support is provided.

All our vacancies are based on the Pinderfields Hospital site, but team members could work within our other hospital facilities, including on the Dewsbury Hospital site.

The Trust offers a flexible approach to varied working patterns to suit staff needs. The Clinical Coding Department encompasses this approach through an agile working rota which offers staff the flexibility to work from home based on personal circumstances and service need.

The Trust is committed to its staff and their development and to equal opportunities and diversity. Applications are welcomed from all sections of the community.

Working hours can be considered around commitments/availability and the needs of the service.

If you have significant clinical coding experience using the ICD10 and OPCS-4 classifications and have attained the National Clinical Coding Qualification UK (ACC), enjoy communicating effectively with a broad range of key stakeholders, whilst managing your time effectively to work accurately and meet competing deadlines, then this is the post for you.

Applications will also be considered from candidates who have completed their Clinical Coding Standards Course and Clinical Coding Standards Refresher Course, who are working towards becoming a qualified.

Main duties

* Screen medical records, discharge summaries, histopathology results and other data sources to extract clinical information relevant to a patient’s 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 the M360 Solventum encoding system supported by International Classification of Diseases (ICD 10) and Office of the Population of Censuses and Surveys (OPCS 4) coding classifications.
* 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 knowledge in accordance with national clinical coding standards changes.
* 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 3 years and specialty workshops where appropriate.
* 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.

Essential person specification requirements

Qualifications:

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

Experience:

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

Knowledge and Awareness:

* Knowledge of the importance of confidentiality, the Data Protection Act and Caldicott Principles.
* Thorough knowledge of Patient Administration Systems.
* Understanding of how acute hospital services function in relation to patient experience.
* Awareness of own limitations.


Be part of MY team

We are an acute trust caring for over one million people in Wakefield and Kirklees. Our 10,000 staff work in patients’ homes, the community, and our three hospitals in Pontefract, Dewsbury, and Pinderfields (Wakefield). We prioritise our people and values so we can deliver the best possible care to patients. Our team is friendly, passionate, and innovative, always seeking better ways to work.

We support work-life balance and foster a diverse, inclusive environment where everyone belongs. Our staff networks offer safe spaces to share ideas and concerns so we can increase awareness and appreciation of equality, diversity, and inclusion. We welcome applicants from all backgrounds and especially encourage members of the LGBTQ+ community, ethnic minority groups, and people with disabilities or neurodivergence to apply, as they are currently underrepresented in the Trust.

If you value caring, high standards, improvement, and respect, join the MY team to make a difference every day.

Application guidance:
We understand that more applicants are using AI technology to help with their applications. While these tools can be useful, they cannot fully capture your skills, knowledge, and experience. It’s important that you personalise your application. Relying solely on AI is not recommended, as it may reduce your chances of success. Our screening process is thorough, so if you have used AI, please make sure to disclose this on your application form.

Our benefits

* Access to the NHS pension plan
* Generous holiday allowance of 27 days plus bank holidays, increasing with 5 and 10 years of service
* Exceptional employee health and wellbeing services
* Extensive benefits and support, including:
* Onsite nurseries and childcare salary sacrifice scheme
* Cycle to work scheme
* Home electronics scheme
* Car lease salary sacrifice scheme
* Working carers support and advice, carers network and carers passport
* Flexible working options and family and carer-friendly policies
* Established staff networks, including LGBTQ+ and Race Equality
* Career progression, training and support

Skilled worker sponsorship

You can find out more about skilled worker and health and care visas on our careers site .

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