Senior clinical coder

SECTION 1- MAIN RESPONSIBILITIES: To accurately abstract and analyse all relevant clinical information from case notes and electronic patient records for all inpatient, day case and outpatient episodes. To be responsible for the translation of such clinical information into a coded format using ICD 10 and OPCS classifications, adhering to their national and international classification rules and conventions. To utilise all systems; Lorenzo, SimpleCode, PACS, TGH Portal, C/Cube and others, as appropriate to ensure that accurate and consistent information is recorded To ensure that clinical data is entered into the Lorenzo EPR for all inpatient, day case and outpatient activity in accordance with DoH and Trust deadlines. This will ensure the Trust recovers appropriate income under the Payment by Results scheme. To develop and maintain the expertise and skills necessary to code accurately in all clinical specialties and expand skills to meet requirements in clinical coding through seminars and meetings, and by attending specialist workshops and training courses as required. To rotate between specialties as requested to assist own Personal Development and Career progression. To have an extensive working knowledge of anatomy, physiology and medical terminology. To demonstrate effective organisational and time management skills with the ability to work independently and as part of a team. Be highly motivated and lead by example to motivate other team members. To understand and maintain the need for accuracy of clinical coding to the highest level of specificity and consistency as this has a direct impact on the finance department and potential income of the Trust. To communicate effectively with clinicians, nurses and managers on matters concerning coding by attending meetings with clinicians and multidisciplinary teams reporting on the status of clinical coding to the department and discussing coding rules and guidelines. Answer questions with regard to coding, thus raising awareness of the importance of clinical coding. To participate in the development, training and mentorship of new staff. To have a comprehensive knowledge of payment by results (PBR) and healthcare resource groups (HRGs) and provide guidance to less experienced coders. To participate with the department clinical coding audits to include monthly quality checks. To work with our Clerical Assistants to analyse reports from Lorenzo EPR to identify uncoded episodes, using the reports to manage workloads and contribute to departmental planning in order to meet targets for submission of data. To take responsibility for all coding issues requiring resolution and to ensure that the Operational Clinical Coding Manager is kept informed of any developments, which may affect the provision of an efficient and effective coding service. To resolve any documentation and/or coding queries by consulting with colleagues and by liaising with medical staff for clarification of information. Follow up all responses with relevant staff. To identify and validate hospital spell details on the EPR system against the information in the case notes. To report any details found to be incorrect to the Operational Clinical Coding Manager for onward reporting to the data quality team. To remove or amend clinical codes as directed by the Operational Clinical Coding Manager or a Coding Auditor and re-input clinical codes as required. To take responsibility for keeping up to date with current issues and developments within the coding department and implement changes to coding rules and ensures team members follow suit To report serious problems with documentation through the Trusts incident reporting mechanism. To identify and raise any coding issues which cannot be resolved internally with the Operational Clinical Coding Manager, and where necessary following the NHSE Query Mechanism process. To play an active part within Divisional Teams advising on operational practices with the aim of achieving high quality clinical coded information. Possess motivation and persuasion skills and use these with trainee clinical coders, management and clinicians to achieve high quality information of clinical coded data. Assists in the maintenance of a team based working environment including the appraisal of clinical coding clerical support. Liaise with medical, clerical and secretarial staff in producing good working practices i.e. agreeing improvement to ensure accuracy, timeliness and completion of clinical coding developing and maintaining any necessary processes to ensure the availability of medical notes. To update personal copies of classifications and instruction manuals to reflect changes in national standards when notified by the Terminology Classifications Delivery Service. Maintain patient and staff confidentiality at all times. Ensure that information processed for both patients and staff is kept accurate, confidential and secure in line with GDPR and the Trust security and confidentiality policy. Through meeting personal objectives, contribute to the broader objectives of the Performance and Informatics Directorate and the Trust. SECTION 2- KNOWLEDGE AND SKILLS The achievement of quality and timeliness is set within the Trust Wide Objective, which requires each member of staff to participate and ensure quality, is assured in every aspect of their work. Each coder is required to ensure that: Their work is submitted accurately and completely first time. Although part of team, coders will be expected to work unsupervised, on their own initiative, organising and prioritising individual workload in order to meet Trust Deadlines. To ensure coding skills are continually being broadened and updated, all coders are expected to attend training courses according to Terminology Classifications Delivery Service training standards, acquiring increasing levels of competency. Coders will be expected to develop the ability to code in all specialties in the Trust following appropriate training and to code any new specialties the Trust takes on and any new coding schemes. Excellent analytical skills that require coders to make an objective decision from clinical information extracted from case notes to reach the correct diagnostic and operative procedure codes that impact on Trust income. A sound knowledge of medical terminology, anatomy and physiology is required To take responsibility for pursuing his/her own development in accordance with an agreed Personal Development Plan. A wide knowledge of all Trust policies is necessary when dealing with patient information e.g. Confidentiality, Data Protection Policies Communication skills are essential when dealing with the variety of Health Care Professionals both within our own Hospital and other NHS Trusts to ensure that no breach of confidentiality to the patient or litigation to the Trust. The knowledge of Medical Records and the filing system, and of all departments, secretaries and consultants is also essential in the process of locating case notes necessary for the coding process. SECTION 3- EFFORT AND ENVIRONMENT A substantial amount of physical effort is required as part of their daily activities. Staff are required to handle case notes that can sometimes be heavy. Due to the nature of clinical coding, staff are required to sit and concentrate for long periods with prolonged VDU use. Extreme concentration is necessary to the thought process for clinical coding. Case notes need to be clearly read in the extraction of information to assign the correct codes. Incorrect assignment could lead to underfunding of the Trust with the wrong HRG being assigned Clinical Coders are exposed to clinical information describing distressing symptoms and treatments, including photographs, during the extraction of patient data, which may affect them emotionally.