Clinical Coder

At BTHFT we believe that coded data is a critical component in shaping patient care and improving outcomes. The Clinical Coding team play a vital role, ensuring complex information from a wide range of clinical systems and services is coded as accurately as possible to produce accurate and useful data for users at all levels of the organisation, driving improved decision making about patient care.

This role will require working with staff at a range of levels within the organisation such as; information staff, service users and leads, clinicians and clinical teams and other relevant stakeholders including heads of services/directors.

At BTHFT we believe that coded data is a critical component in shaping patient care and improving outcomes. The Clinical Coding team play a vital role, ensuring complex information from a wide range of clinical systems and services is coded as accurately as possible to produce accurate and useful data for users at all levels of the organisation, driving improved decision making about patient care.

This role will require working with staff at a range of levels within the organisation such as; information staff, service users and leads, clinicians and clinical teams and other relevant stakeholders including heads of services/directors.

Our People Charter outlines the behaviours we can expect from one another and what you can expect from Bradford Teaching Hospitals Foundation Trust:
We value people

We are one team

We care

We’re keen to meet people who share these values and are passionate about delivering the highest quality of care to our patients.

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

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 motivat