Clinical Coding Specialist Health Group Lead

Job description

Duties and responsibilities

To identify uncoded activity be reviewing the daily discharges list / uncoded lists

To visit ward and non-clinical areas to extract the necessary clinical details from case notes to inform the clinical coding process.

Using other source documentation and systems to identify, analyse, extract and interpret complex information relating to the patients stay

Using coding tools (Coding Manual, ICD and OPCS classification books, coding clinics and Classification Service resolutions) identify the codes to be applied to each Finished Consultant Episode

At all times adhering to national standards and local coding policies exercise judgement and initiative in selecting the appropriate clinical codes to ensure that the coding accurately reflects the individual patient episode.

To access a variety of information systems, e.g. pathology, radiology, and other clinical systems in use in the Trust, to obtain other information to inform the coding process and to ensure the completeness and accuracy of coding by checking results.

To use own discretion and judgement to analyse often complex information available using coding rules and conventions to translate this information into the appropriate codes as set out by national guidance (OPCS 4 Office ICD-10) or any classification that may be implemented in the future.

To enter coded clinical data onto the Trust encoder (3M Medicode) ensuring accuracy, completeness and timeliness at all times as failure to code episodes accurately will have a direct effect on Trust income.

To routinely code a minimum of 40 episodes per day on average.

To identify data quality queries on the patient information system, for example patients not admitted, transferred and discharged, wrong Consultants and dates and address the issue with the Assistant Clinical Coding Manager.

To negotiate with clinicians over interpretation of coding guidance, escalating to the Assistant Coding Manager as appropriate.

To deal with coding queries as and when is necessary throughout the working day and to communicate complex coding rules to medical, clinical, administration staff.

To be responsible for prioritising the workload of your Team using the uncoded reports available, ensuring that to departmental targets are met and to advise the Assistant Coding Manager of any hindrance to the achievement of these targets, providing support and supervision to more junior coders. 

 To work with other staff groups (clinical, managerial and administrative) within a specific division to resolve any coding or classification queries. Communicating complex coding rules and key terms and conventions to these staff groups, working to ensure that the coding reflects the patients’ clinical condition and treatment and that the Income generated (via HRG allocation) is accurate.

Motivating all staff in the Coding Team and within the divisions by discussion and analysis to ensure that the Clinical documentation and the subsequent Clinical coding is of a high quality To participate in discussions of coding problems and issues with other clinical coders, for example at monthly departmental meetings.

To demonstrate a high degree of compliance and discipline in accordance with complex changing terminology and their relationship to new surgical techniques and all new changes in the diagnostic field as related to the classifications and medicine.

Working with the Coding Auditor to ensure coding is accurate by participating in planned and spot check audits in an on-going basis, feeding back results and areas of learning.

Be responsible for conducting the annual appraisals for staff working in their Team, agreeing objectives and highlighting identified coding training needs to the Assistant Coding Manager.

Where staff performance is below the required level you will be required to work with the staff member in line with Trust Performance Policy to improve their performance, supporting the Assistant Coding Manager if any formal or informal action is required.

This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.This job description may be subject to change according to the varying needs of the service. Such changes will be made after discussion between the post holder and the manager. All duties must be carried out under supervision or within Trust policy and procedure.

Additional Information:

The role is subject to a 20% recruitment and retention supplement, to be reviewed at 12 months.

Per annum, there will be a 5% high cost area supplement.

Remote / home-working is available for this role.

Person specification

Qualifications

Essential

• National Clinical Coding qualification (degree level)
• Evidence of attendance on Clinical coding speciality workshops, with the last 2 years
• Evidence of attendance to a Clinical Coding refresher course, within the last 2 years

Desirable

• Evidence of post graduate qualification
• ECDL
• Leadership and Management qualification (training will be given)

Experience

Essential

• Experience in managing a performance output-based service
• Demonstrable in-depth specialist Clinical Coding experience across a wide range of Specialities, in an Acute Trust setting

About the employer