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Key result areas:

Abstract, analyse and enter correctly coded data into PAS (Patient Administration System) within agreed timescales.

Deal with complicated queries; liaise with clinicians and attend multi-disciplinary team meetings where required.

Locate and collate all appropriate source material, for example, missing case notes, histology.

Liaise with colleagues to distribute workload.

Communication

Able to communicate clearly and with confidence; able to articulate complex rule sets.

Able to offer advice and solutions, demonstrate empathy, attention to detail, leadership, reliability and business acumen on all matters relating clinical coding.

Communicate with Clinicians and Business Unit Management Teams, providing and receiving information that may be of a sensitive or potentially contentious nature.

Take an active part in general departmental meetings to ensure knowledge and learning is widely communicated.

Work with auditors in delivering feedback from audit results, reviewing personal development plans for the team/

Assist clinical teams with the research and provision of information for clinical audit and other purposes.

Ensure appropriate and effective planning, communication and management of clinical coding projects which cross business units.

Maintain and build on specialist knowledge and coding skills through regular peer communication identifying appropriate training opportunities.

Be able in the use of the hospital administration systems for the input of clinical data and the authorised amendment of detail, paying particular attention to accuracy, timeliness and confidentiality and using this knowledge to assist and train others.

Access electronic software systems extract information to supplement clinical coding of the patient record and train others to do likewise.

Regularly review and, if necessary, revise own working practices to take account of the department, Trust and NHS mandatory requirements.

Use knowledge of HSCIC Healthcare Resource Group (HRG) code assignment logic to advise Clinical Coders on diagnostic and procedure code assignment.

Have knowledge of the importance of clinical coding and its uses and an understanding of data quality requirements.

Use and maintain an extended knowledge of medical terminology, anatomy and physiology, to assist in the selection and application of clinical codes and to investigate and resolve possible inconsistencies between source data and test results.

Keep up to date with development and innovations in healthcare provision in Secondary Care.

Analytical and Judgmental 

Work with the Information, Contracting and PAS Teams to improve data quality.

Abstract and analyse complex patient clinical records.

Use judgement to escalate complex cases where the procedure undertaken may not be readily code-able.

Use judgement to resolve complicated coding queries on behalf of the team where information available is ambiguous or there is differing opinion.

Be familiar with external clinical coding audit requirements, and standards, meeting with external auditors as and when required.