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Detailed job description and main responsibilities

• To abstract and analyse complex information in the patient’s case notes or other source of documents and translate the medical terminology into clinical codes to the provisions of ICD-10 and OPCS-4 and Clinical Coding Manual, and to input the coded information on to the organization’s clinical information system.
• To maintain national coding standards and adhere to national and international conventions to assign uniform codes, which represent a complete picture of the patient’s hospital stay.
• In accordance with expertise and knowledge gained through all training/educational processes, code to profession standards and conventions, and to ensure the high quality clinical coded data are provided with agreed time scales. This will require focus, motivational negotiation, and judgement.
• To be able to work under pressure maintaining accuracy especially around monthly closedown and the refresh period.
• To check the accuracy of admissions, transfer and discharge details in the patient’s medical record and to identify errors on the clinical information system.
• To answer Clinical Commissioning Group challenges in code assignment in a timely manner.
• Coding business analysts are required to create and maintain strong stakeholder engagement with Consultants and their clinical teams to ensure quality and depth of clinical coding is achieved. In order to achieve this they are required to communicate complex coding rules to various medical, clinical and administrative staff at all levels.  Communication can be via telephone, in person, written, or by email.
• The ability to challenge, question and clarify by reasonable argument the adherence to national standards relating to clinical coding.
• To act as mentor to less experienced coding staff in understanding clinical coding rules. PbR and HRG (Healthcare Resource Groups), therefore having a sound knowledge of these processes themselves.

       Failure to code accurately could lead to hundreds of thousands of pounds of lost income for the Trust.

• To manage and prioritise own workload for designated areas within the department.
• To be proficient in the Trust’s many IT systems, including iPM, ICE, Clinical Correspondence, Evolve (for ERDMS) and the Clinical Income Dashboard system.
• To access the Trust histopathological database (ICE) to extract the relevant information when assigning appropriate clinical codes.
• To liaise and attend meetings with clinicians and other medical staff on a regular basis to ensure that defined data quality standards are met, and maintain an ongoing expertise in order to discuss and validate complex clinical data and procedures with clinicians.
• Understand the impact of coded data on the business aspects of the Trust, and thus be able to provide the information and advice to all health professionals and administrative staff of the nature and complexity of clinical coding and its purposes in areas such as patient care, clinical governance, clinical audit, finance, budgeting, data quality and research.

• To maintain a portfolio of evidence and professional accreditation through attendance and participation in ongoing internal and external training programmes; continuously updating comprehensive knowledge and understanding of medical terminology, anatomy, and physiology and its applications to clinical coding.
• To work as part of the team to supervise and support the training of new and less experienced coders; providing cover for colleagues as and when required; assisting with regular internal audits of clinical coding and in the customisation of the coding process (systems and procedures) to further the efficiency within the Trust – with awareness of local agreed variations to coding rules on proposed changes, as well as report to the Clinical Coding Manager any contradictions to national guidelines.
• Maintain a flexible attitude and response to change in job content or organisation in order to maintain or improve the quality of service provided to patients, the Trust, and to other customers.
• To visit hospital wards and other departments as necessary to view source documents (case notes) required to complete coding; to collect source document sheets (e.g. discharge summaries); to take reasonable steps to chase up outstanding source data. Source documents will increasingly include electronic records.
• To participate in discussions within the coding business group to facilitate improvements surrounding coding problems and issues with data quality, as well as providing meaningful reports and presentations at monthly departmental and stakeholder meetings.
• To plan and prioritise own workload to meet departmental expectations and to advise the leadership team of any hindrance to the achievement of desired outcomes for the coding service.
• To assist in the continuing development and expansion of the Clinical Coding Department in order that high quality data can be collected and produced without delays.
• Quality and Assurance checks on junior and senior coders. Providing a detailed report based on 15 case studies a week highlighting areas of concern.
• Participating in monthly Income Recovery projects.
• Working alongside the Waiting List team to provide them with accurate codes for diagnosis and procedures.
• To assist with the development of departmental policies.
• To undertake all reasonable requests from the Head of Clinical Coding Services.
• To maintain the strictest confidentiality.