Lead Clinical Coder

3 weeks ago

Worcester, Worcestershire, United Kingdom Worcestershire Acute Hospitals NHS Trust Full time

Position Overview

We are pleased to announce a vacancy for a Lead Clinical Coder within our Clinical Coding Team at Worcestershire Acute Hospitals NHS Trust. The ideal candidate will possess accreditation as a Clinical Coder, demonstrating enthusiasm and a collaborative spirit.

This position primarily allows for remote work, with the option to work on-site if preferred. We promote a flexible working environment to support a healthy work-life balance, ensuring optimal performance from our team.

Key Responsibilities

The primary function of a Clinical Coder is to deliver an efficient, precise, timely, and consistent clinical coding service to the Trust, ensuring that all coding quality benchmarks are met.

Responsibilities include:

  • Accurately coding diagnoses and well-defined procedures for inpatient and day case activities in accordance with ICD10 (International Classification of Diseases) and OPCS4 (Operation Procedure Classification Standards).
  • Providing essential data for the effective management of the Trust, which directly impacts the Trust's revenue in alignment with the 'Payments by Results' framework.
  • Supporting clinical audits, clinical governance reporting, benchmarking, and medical research initiatives.

About Worcestershire Acute Hospitals NHS Trust

Our mission is straightforward - Putting Patients First. We seek exceptional individuals who can contribute to this goal.

Worcestershire Acute Hospitals NHS Trust is a prominent acute and specialized hospital trust, offering a variety of local acute services to the residents of Worcestershire and more specialized services to a broader population in Herefordshire and beyond.

Operating from three hospital sites, our workforce exceeds 7,000 dedicated professionals, recognized for delivering high-quality, patient-centered care. You could join this esteemed group.

We are committed to attracting the best talent to help us realize our Vision - collaborating to provide the highest quality healthcare for our communities, while leading and supporting our teams to progress forward. Our core values, which we expect all staff to embody, are integral to our daily operations.

Our Objectives Include:

  • Delivering the best services for local communities
  • Ensuring the best patient care experience and outcomes
  • Optimizing resource utilization
  • Recruiting and retaining the best talent

We are proud to have achieved Timewise accreditation, reflecting our commitment to fostering flexible working arrangements within our organization.

Job Responsibilities

Post Title: Lead Clinical Coder

Pay Band: 5 plus 15% R&R

Hours: Full-time

Department: Finance Directorate

Reports to: Clinical Coding Manager

Key Working Relationships:

Consultants, Clinical Staff, Ward Personnel, Medical Secretaries, Health Records Staff, Information, Performance & Data Quality Teams.

Job Purpose:

To abstract, analyze, and accurately translate diagnostic and procedural information using the International Statistical Classification of Diseases and Related Health Problems (ICD10) and the OPCS Classification of Interventions and Procedures version 4, adhering to local and national guidelines. This role supports the Trust's operational needs and enhances patient care by coding all inpatient episodes within specified deadlines. Additionally, the role involves liaising with clinical staff to resolve queries and gather missing source materials for coding purposes.

Key Duties:

  • Utilizing the Trust's Electronic Patient Record (EPR) and scanned case notes, including letters, test results, and operation sheets, alongside a solid understanding of medical terminology, to verify patient diagnoses and procedures performed during their inpatient care.
  • Employing the Index and Tabular of ICD10 and OPCS4 in accordance with coding standards to accurately code patient records, using judgment to navigate complex cases.
  • Facilitating the coding process through proficient use of the encoder to ensure timely coding of all inpatient episodes.
  • Communicating intricate coding rules and conventions to clinical and administrative personnel, as well as external agencies.
  • Collaborating both independently and as part of a team to meet monthly coding deadlines, fulfilling the Trust's internal and external information requirements.
  • Engaging in continuous learning to code across all specialties, including general, maternity, and community coding, to support self-development and ensure comprehensive coverage during staff absences.
  • Coordinating with medical and clerical staff to identify and capture missing data items within required timelines.
  • Reporting or rectifying any patient episode discrepancies through thorough cross-referencing with case notes.
  • Participating in internal and external Clinical Coding training to maintain and enhance coding skills.
  • Utilizing coding manuals and resources to support the coding process and stay updated with coding practices.
  • Mentoring less experienced coders and addressing queries as needed.
  • Providing guidance on appropriate coding, ensuring unresolved queries are escalated to the Clinical Coding Auditor or Coordinator.

Other Requirements:

To maintain accurate records in both manual and computerized systems in line with established policies and procedures.

To adhere to Trust policies regarding confidentiality and information security.

To undertake any additional duties commensurate with the role's grade.

Competence:

The post holder is responsible for ensuring their actions remain within their competence. If there are any uncertainties regarding their capabilities, they should consult their line manager or supervisor.

Confidentiality:

The post holder must uphold the confidentiality, security, and integrity of information related to patients, staff, and other Health Service operations.

Health and Safety:

Employees must be aware of their responsibilities under the Health and Safety at Work Act and relevant Trust Health and Safety Policies to maintain a safe environment for all.

Infection Control:

Employees must accept personal responsibility for Infection Prevention and Control practices and comply with all relevant policies.

Non-Smoking Policy:

The Trust adheres to a no-smoking policy across all premises, promoting a smoke-free environment for patients, staff, and visitors.

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