Detailed job description and main responsibilities

Main Tasks and Responsibilities

 §  To analyse and interpret a complex mix of clinical information for all relevant patients to abstract diagnoses, co-morbidities, medical and surgical procedures, medical status and relevant personal/family history information; accurately assigning codes using the International Statistical Classification of Diseases and Related Health Problems – Tenth Revision (ICD-10) and The OPCS Classification of Interventions and Procedures – Fourth Revision (OPCS 4); ensuring that coded information is accurate, complete and timely, thereby contributing to essential management information for the Trust. This is of paramount importance to prevent the loss of income to the Trust.

§  Actively liaise with healthcare professionals to verify incomplete or contradictory clinical information.

§  To organise and prioritise your own workload as appropriate to meet the agreed local and National deadlines.

§  Understand the impact of coded data on the business aspects of the Trust and thus be able to provide broad information and advice to all health professionals and administrative staff of the nature and complexity of clinical coding and its purposes.

·         Where the opportunity arises be proactive in raising awareness of the importance of clinical coding and encouraging healthcare professionals to get involved with the coding by encouraging them for example to validate the coding for their activity.

·         To act as a clinical coding lead as and when required for a designated specialty. Building strong working relationships with the clinicians and other relevant staff within that specialty and be the main point of contact should they have any queries. Continually gaining knowledge within that area to support other coding staff and ensure the highest levels of coding accuracy;

§  Reporting complex coding queries, documentation and systems data quality inconsistencies, to the Clinical Coding Data Quality Assurance lead or Clinical Coding Management;

·         Work with Clinicians/Healthcare Professionals/Clinical Coding Management and Finance to ensure local policies are implemented if necessary, are kept up to date and do not contravene any national standards;

§  Ensure attendance and participation in ongoing internal and external training and professional development opportunities; continuously updating your comprehensive knowledge and understanding of medical terminology, anatomy and physiology, and its applications to coding.

·         Be aware that you will be exposed to disturbing, distressing and detailed written and photographic information.

§  Working as part of the team to provide cover for colleagues as and when required.

§  Support any trainee coders as required.

§  Assist and participate as necessary with regular audits of clinical coding and other information performed by the DQ Assurance lead, Clinical Coding Manager, or other stakeholders.

§  Contribute to continual improvement of the coding process (system and procedures) to further the efficiency for the Trust.

§  To be proficient in the use of Microsoft products.

§  Maintain a flexible attitude and response to changes in job content or organisation to maintain or improve the efficiency and quality of service.

§  Advise and assist where necessary, with the facilitation of the coding of outpatient episodes and of waiting lists.

§  To ensure all relevant Trust wide policies are followed such as: Health and Safety and the Confidentiality Policy and Data Protection Act.

§  The post holder from time to time will need to attend The Hillingdon Hospital site and/or Mount Vernon Hospital site as deemed appropriate to carry out their duties in order for the continuation of the service, most common reasons will be when equipment might fail, access to the internet is lost or to attend training that must be done in person

§  Any other duties as requested by the Clinical Coding Management within the scope of the job profile as required.