Clinical Coder

at  Bradford Teaching Hospitals NHS Foundation Trust

JOB DESCRIPTION JOB DETAILS Job Title: Trainee Clinical Coder/Clinical Coder Reports to: Clinical Coding Team Lead Accountable to: Director of Informatics Grade: 3 or 4 dependant upon experience Unit/Department: Informatics Location: Based at Bradford Royal Infirmary with hybrid working JOB PURPOSE The jobholder will be responsible for delivering accurate and timely clinical coding data for all in patients and day case activity within appropriate timescales. Responsibilities include the extraction of relevant data from case notes and other sources and translating this information into codes conforming to National Standards to fulfil the Trust’s internal and external information requirements. To undertake all training required and attend courses to extend knowledge and skills in applying coding standards to multiple specialties across the trust. To take part in data quality improvement measures within the department by participating in audit and other measures.
Coded clinical data is essential for effective management, it is used to support service agreements, clinical governance reporting and benchmarking and has a direct impact on income. JOB DIMENSIONS The department codes diagnostic and procedural activity for all in-patient and day case activity in the Trust - approx. 125,000 FCEs pa, utilizing an electronic patient record. Coders are expected to accurately code routine and complex medical information in detail using standards maintained nationally conforming to all pre-set deadlines.
National standards are set within the classifications of ICD 10 and OPCS 4 and maintained by the Classifications Service. This role requires an organised approach to the work load and the ability to work in a very busy environment where a high degree of accuracy with attention to detail and experience of working to tight deadlines is paramount. ORGANISATIONAL CHART KNOWLEDGE, SKILLS AND EXPERIENCE REQUIRED See Person Specification PRIMARY DUTIES & AREAS OF RESPONSIBILITY Extract relevant clinical information from the Electronic Patient Record (EPR), translate and assign accurate diagnostic, intervention and procedure codes using ICD10 and OPCS-4 classifications Adhere to national standards and local policies and take responsibility for updating these as and when required Be aware and open to translating information of a distressing nature Undertake all necessary training, including the Clinical Coding Refresher Course Work towards achieving the National Clinical Coding Qualification (NCCQ) and attaining Accredited Clinical Coder (ACC) status Raise coding related queries with other members of the Coding Team as and when required, including Senior Team, to ensure correct resolution Participate in yearly appraisals with the Clinical Coding Manager Highlight issues in information sources and advising on appropriate ways in which these can be resolved. To promote the role of the Clinical Coding Department in a positive manner both internally to the Foundation Trust and to external stakeholders.
To ensure that new developments are communicated to members of the coding team and management when appropriate. To code a highly complex and specialist caseload in accordance with classification and national rules. Assist in the development and implementation of local coding policies. Assist in the implementation of changes to the coding service as directed by local and national policy and procedure.
Working with the Clinical Coding Senior Team to ensure efficiency, national standards of clinical coding and best practice operate within the department. To provide accurately coded clinical information within established deadlines, making recommendations to improve service delivery. Participate in data quality and coding audit programmes involving communication with clinicians and full participation in the audit process. To attend seminars and training courses both internal and external to the Trust.
Undertake other tasks as required. COMMUNICATION & WORKING RELATIONSHIPS The post-holder will be expected to communicate with a wide range of staff groups throughout the Trust on a daily basis. This may involve complex or technical issues and will require motivation, combined with negotiation, communication and training skills. Communication and knowledge sharing with staff within the Business Intelligence function and other teams within Informatics will be essential.
Significant liaison and communication with information users outwith Informatics, both within and outwith the Trust, will be required on a regular basis. Key Working Relationships: Operational Lead Business Intelligence Clinical Coding Senior Team Business Intelligence Manager and BI analysts Divisional managers and analysts Data Quality Informatics function; I.T., Data Warehouse etc. Operational and clinical staff at all levels across divisions Finance function SPECIAL WORKING CONDITIONS Bradford Royal Infirmary with hybrid working JOB DESCRIPTION AGREEMENT Jobholders Signature: ____________ Date: ___ Head of Departments Signature: ________ Date: ___ Head of Departments Job Title: _______________

Please refer the Job description for details