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Detailed job description and main responsibilities

KEY DUTIES

• Ensure accuracy and completeness of clinical coding which underpins the Payment by Results framework and national clinical coding requirements.
• Abstraction of clinical information from the health record and translation of that medical terminology using ICD-10 (diagnostic codes) and OPCS 4 (procedure codes) into a form that can be tabulated, aggregated and sorted for statistical analysis and to support the Payment by Results agenda applying national rules and conventions to agreed standards.
• Demonstrate effective organisational and time management skills with the ability to work independently and as part of a team. Be highly motivated and lead by example to motivate other team members.
• Carry out clinical coding to the highest level of specificity using the three dimensions to coding accuracy thus giving complete and accurate data of a high quality that is consistently recorded.
• Routinely extract pathology/histology/radiology information and use for more accurate clinical coding in a timely fashion in accordance with the clinical coding deadlines.
• Work on own initiative in collecting information by whatever means required. This could include entering very specific areas of the Trust.Exercise diplomacy and confidentiality in pursuit of collecting this data.
• Participate in the training and mentorship of less experienced coders and advise Novice and Junior Clinical Coding Officers on coding issues.
• To work towards gaining experience in other clinical coding areas that fall outside the standard clinical coding processes such as Burns & Plastics, Obstetrics, Gynaecology and Oncology.
• To act as first line enquiry for requests for information either in person, by email or via the telephone.
• Promote and implement clinical coding policies and procedures and national guidelines
• Assist the Clinical Coding Manager to identify any complex issues in clinical information contained in the medical record and electronic systems that contradicts clinical coding guidelines.
• Assist Clinical Coding Manager to identify discrepancies in computer/hard copy information ensuring accurate data quality.
• Monitor data quality and clinical coding standards in line with local and national guidelines. Report any complex coding issues as directed for verification and/or send to the Clinical Coding Classification Service help desk.  Share all responses with relevant staff.
• Remove or amend clinical codes to Finished Consultant Episodes (FCEs) as directed by the Clinical Coding Manager or Information Services Department. Re-input clinical codes as necessary.
• Communicate effectively with clinicians, managers, information, finance and other staff members to ensure high quality of coded data. Possess the  ability to provide complex clinical coding advice and information to colleagues within the NHS.
• Liaise with clinicians, researchers and healthcare professionals on a regular basis to provide and help with information as required. Be able to explain the requirements of the classifications and how to implement them. 
• Be prepared to attend multidisciplinary meetings when required to promote clinical coding, the rules and conventions that surround them and raise awareness of the importance of accurate data
• Promote a thorough knowledge and understanding of the rules and conventions that surround the Classifications of Diseases and Healthcare Related problems, tenth revision (ICD-10) and Office of Population Census and Surveys fourth revision (OPCS-4) to all levels of staff within the Trust.
• Further develop a team approach within the service leading by example in all areas of clinical coding

CLINICAL & PROFESSIONAL RESPONSIBILITIES

• To take every reasonable opportunity to maintain and improve your professional knowledge and competence.
• To participate in personal objective setting and review, including the creation of a personal development plan.
• Maintain an excellent knowledge of Medical Terminology and Anatomy and Physiology.
• To attend regular relevant training/workshop sessions.
• Maintain a high level of competency in the recording of clinical codes and completion of assessments as and when required to measure accuracy and quality of the coded data.
• Keep up to date of the regular updates and amendments to ICD-10 and OPCS

ADMINISTRATIVE RESPONSIBILITIES

• To validate the hospital admission details on the PAS system against the information in the case notes. To report any details found to be incorrect to the Data Quality Team and to highlight areas of concern with information in the case notes

TEACHING & TRAINING RESPONSBILITIES

• To continue to update clinical coding skills attending mandatory clinical coding specialty workshops and refresher courses.