Clinical Coding Department Role

The Clinical Coding Department is responsible for abstracting and analysing complex clinical information from patients' records and translating this into a coded format in line with National Standards.

To enter the final encoded data onto the appropriate computer systems to meet essential Trust requirements for statutory information and financial flows.

You will work as part of a team of experienced trained staff, the job will involve rotation between duties working on all specialties.

To work as a senior member of the Clinical Coding team in supporting & mentoring Clinical Coding Officers and assist the Clinical Coding Manager in ensuring accurate and timely clinical coding is achieved for all patient activity.

Senior Clinical Coders are expected to work on their own initiative to collect, collate, translate and assign codes to clinical information relating to the diagnoses and operations for patients admitted to hospital. This is in accordance with local and national coding practices and to meet local quality and timeliness standards.

To provide codes and appropriate details for all those seeking to extract clinically coded information from the Patient Information Management System.

Responsibilities

• Review and interpret complex clinical information from patient health records and a range of clinical systems, applying your knowledge of medical terminology, anatomy and physiology
• Accurately code inpatient and day case activity using ICD-10 and OPCS-4 classifications, in accordance with national and local clinical coding standards, rules and conventions.
• Ensure coded information is accurate, complete, consistent and submitted within agreed Trust timescales.
• Act as a key coding contact for designated specialties, building positive working relationships with clinical teams and supporting the resolution of complex coding queries.
• Liaise with clinicians and their teams to clarify clinical documentation where this is required to support accurate coding.
• Provide guidance and support to trainee, junior and less experienced Clinical Coders, including mentoring, checking work and helping colleagues develop their coding knowledge and confidence.
• Support the induction of new team members and work with the Clinical Coding Manager to identify learning and development needs.
• Participate in clinical coding audits, review findings and contribute to improvements that support consistently high standards of coded information.
• Support the Clinical Coding Manager in developing and implementing local processes and guidance in line with national standards.