Job summary
1. To accurately extract relevant clinical information from the Patient Health Care Record and to assign appropriate codes following established National Coding Guideline
2. To interface with clinicians, healthcare workers, and other relevant personnel in order to ensure coding accuracy and integrity are maintained at the highest level
3. To mentor and support all junior staff
Job responsibilities
Communication and Team Working
4. To seek guidance from Trust clinicians to address coding issues and discrepancies related to their specific specialities
5. Assign correlation of data from electronic patient record to 3M Medicode software for data, service improvement and HRG gathering
6. To promote among clinicians, health care workers and any other associated outside agency, awareness of the Clinical Coding role and its uses within the trust to raise the stature of Clinical Coding as the essence of professionalism
7. Facilitate improved communication within the department and between other departments, clinicians, managers, ward staff and other personnel
8. To interface with other Trusts, offices, and personnel in seeking ways, means, and ideas to improve the coding office processes
Planning and Organising
9. To assist the Team Manager in maintaining departmental performance with regard to quality and quantity by upholding agreed standards
10. To assist the Team Manager in work allocation, supervision and planning tasks to all members of staff
11. Monitor own performance against previously agreed objectives
12. To support the team ensuring monthly targets are met
13. Organise own day to day work task, completing priority coding foremost
14. Operate own workload day to day
Managing People and Resources
15. To take personal responsibility to ensure the correct usage of all resources provided to perform assigned tasks
16. Assist the Team Manager in monitoring performance of junior members of staff
17. To identify and participate in any cost improvement measures as required
Training and Teaching
18. To seek and attend in-house training, workshops, formal training, open discussions, and briefing from various expert sources in order to maintain coding proficiency
19. To seek knowledge and experience levels required to maintain national Accredited Clinical Coder (ACC) status
20. To be responsible for attaining and maintaining proficiency levels necessary to sustain coding data accuracy and integrity
21. Attain and maintain proficiency levels in all tasks within the coding office and perform these duties as required
22. Mentor junior members of staff in speciality coding
23. Mentor junior members of staff in coding direction and assistance
24. Assist the Team Manager in the training and development of junior members of staff as required
25. To maintain IT knowledge and 3M knowledge
26. To maintain medical terminology and coding conventions and to increase skill in long term development
Policy, Service, Research Development
27. Participate in audit and monitoring of standards
28. To participate in the development of an evidenced-based and patient focused service
29. To be responsible for increasing their own professional research knowledge by promoting a questioning and analytical approach to coding
30. Adhere to local coding office Policies and Procedures, conforming to National Standards as established by the Clinical Coding Team Manager
31. Ensure correct procedures are adhered to relating to telephone calls into department and take appropriate action as necessary
32. To work within an overall framework of Clinical Governance
33. To support the Team Manager in the implementation of Trust Policies such as Risk Assessment and Incident Reporting management
34. Comply with patient confidentiality and GDPR at all times
35. Implement agreed Local Polices and Clinical Coding Guidelines, update training materials when changes require
Administration
36. To attend discussions, meetings, and functions that have a direct bearing on the clinical coding process, as required. Ensuring coding processes are not compromised
37. Develop knowledge of the correct procedures and use of the Individual Performance Review (IPR) system
38. To uphold highest levels of efficiency relating to the correct usage of the eCare, 3M Medicode, ICE, Evolve and any other data storage systems required to maintain standards
39. Frequent prolonged effort for workload on a computer
40. Frequent indirect exposure to emotional circumstances
41. Constant requirement for prolonged concentration and sitting for long periods at workstation.
Health, Safety and Security
42. Use and encourage others to be familiar with the personal security systems within the workplace, according to practice guidelines
43. To initiate the emergency alarm when required if assistance is required for staff and patient safety
44. Identify the risks involved in work activities and undertake them in a way that minimises risks
45. Work in line with Health and Safety policies and procedures within the workplace
46. Uses the trust incident reporting system to report any issues that may affect the working environment.
Personal Development/Clinical & Professional
47. To at all times strive to use correctly the following guidelines: International Statistical Classification of Diseases and Related Health Problems (ICD-10) and Office of Population Censuses and Surveys (OPCS-4) within the Trust
48. Maintain National Standards established by the NHS Digital National Clinical Coding Standard Reference books
49. To support the Trust in complying with National Standards, for example CNST, Controls Assurance and National Clinical Coding Standards
50. Judgement for all complex training factors in presentation and feedback scenarios
51. To process and codify patients medical records and any other relevant documentation
Person Specification
Education & Qualification
Essential
52. Accredited Clinical Coder (ACC)
53. Good general education (Degree level or equivalent)
54. Anatomy, Biology, Physiology
55. Certificate in Medical Terminology
56. Clinical Coding Standards Course
Experience & Kowledge
Essential
57. Minimum 2 years NHS experience
58. Refresher course in past 3 years
59. Experience in Team environment
60. Clerical experience
61. Awareness of patient confidentiality and GDPR
62. Working knowledge of an electronic patient record system
63. Working knowledge of Medicode encoder/other encoder
64. Wide speciality coding
Desirable
65. Working with the public
Skills & Abilities
Essential
66. Good interpersonal and communication skills
67. Ability to work calmly in a busy environment
68. Evidence of supporting junior staff
69. Good IT skills
70. Time management skills
71. Polite and efficient manner
72. Group working skills
73. Ability to analyse
74. Able to maintain levels of high concentration
Personal Qualities
Essential
75. Supportive of others and is a team player
76. Motivated
77. Flexible approach to working hours/duties
78. Has an eye for attention to detail
79. Analytical