Trainee Clinical Coder

6 months ago

Harlow, United Kingdom The Princess Alexandra Hospital NHS Trust Full time

We are looking for a highly motivated and enthusiastic individual to join our Clinical Coding team, here at the Princess Alexandra Hospital.

The Training post is an initial 12 months fixed term position. Upon successfully passing of an internal assessment within the fixed term period the position will be become substantive.
- a good, demonstrable understanding of human anatomy & physiology
- a hunger to learn
- attention to detail
- an inquisitive mind
- To provide accurate, timely and complete clinical coding of all specialities
- Undertake Clinical Coding training to develop and enhance coding
- Undertake Clinical coding across all sites (PAH, SMH, HEH), if required.

To assign Diagnosis and Procedural Codes for all inpatient and outpatient episodes, using the International Classification of diseases and Health related problems (ICD-10), and OPCS Tabular list of Surgical Operations and procedures (OPCS 4.9).

To provide accurate information for Hospital resource management, statistical & research purposes.

This is an exciting time for PAHT. Over the next five years we are on a digital transformation journey, leading us to our brand new hospital. You’ll be part of the team leading and supporting our organisation in a diverse and challenging role; a role which can make a significant difference to our patients, staff and the future direction of our services.

Our people demonstrate energy and commitment towards improving the care and experiences provided to our patients and the drive to be an ‘outstanding’ organisation.

It’s never been a better time to join us.
- Extract, assess and interpret clinical information to accurately assign clinical codes as per national standards within strict deadlines, under super supervision
- Assign codes for all diagnosis and procedures in all specialties
- Tabulate codes in the correct order according to World Health Organisation
- Exercise initiative on each coding episode with a certain measure of independent judgement
- Confirm coding on the receipt of histology reports
- Liaise with Clinicians on the conventions to be used with regards to new procedures
- Decipher handwritten case notes using knowledge and experience
- Liaise with Consultants, Nursing, other Medical Staff and Secretaries to ensure that all information is accumulated to accurately reflect the patients stay in hospital
- Check and assess patient information for relevance and validity
- Identify and locate additional information when there is insufficient detail in the case notes
- Clarify discrepancies between clinical diagnoses and histology report where possible
- Update and amend ICD10 and OPCS4 when changes are issued by the relevant bodies
- Adhere to all Internal and external deadlines
- Answer coding queries from a range of sources
- Analyse any incomplete or conflicting information and assign the most appropriate clinical codes to accurately reflect the patient care provided by the Trust.
- Take part in the discussions in order to assign appropriate codes for new operations.
- Report all computer related problems to the IT Helpdesk and follow it up to a successful resolution.
- Identify and report errors found on the COSMIC System e.g. incorrect consultant designation.
- Liaise with clinical, managerial and information staff to resolve coding queries and problems that may arise, including incorrect admission, transfer or discharge information recorded on COSMIC.
- Demonstrate proficiency in accessing and interpreting the Trust’s clinical data systems (such as the pharmacy, theatres, radiology reporting, endoscope reporting electronic discharge summary, clinical management database etc.).
- Collect the necessary medical diagnostic and related operational/procedural data.
- Prioritise workload, meet deadlines and tackle problems systematically and with initiative.
- Provide a sample of work for presentation for auditing as well as participate in the process of coding audit to ensure data quality.
- Undertake specialty change or rotation on an annual basis or when a required change in specialty is identified or requested by the coding management.
- Personal development activities will be undertaken as agreed with the Head of Clinical Coding.
- Successfully completes clinical coding foundation course and post course assessment written examination.
- Sit the NCCQ exam within 3 years of appointment.
- Active involvement in Consultant Mortality Validation.
- In line with Information Governance Requirement 505, coders are expected to regularly attain over 90% coding accuracy in primary diagnostic and procedural coding and 80% coding accuracy in secondary diagnostic and procedural coding.
- To ensure consistency in timeliness and delivery of the Trusts coding deadlines, each Clinical Coder is expected to code at least 35 episodes per day.
- To be accountable for ensuring that deadlines are met and to highlight to management any foreseeable problems or issues that may impact on meeting such dead

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