To provide an efficient and high quality clinical coding service to support the business needs of the Trust, including Clinical Governance, Information Governance and finance by ensuring accurate translation and input of medical terminology.
- To identify uncoded activity be reviewing the daily discharges list / uncoded lists
- To visit ward areas on a daily basis to extract the necessary clinical details from case notes to inform the clinical coding process.
- Using other source documentation and systems o 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 (currently 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 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 relevant Service Manager or PIMS staff.
- To negotiate with clinicians over interpretation of coding guidance, escalating to the Coding Manager and the Head of Coding Analysis 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 and external agencies.
- 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 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 specific clinical specialties 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 Clinical specialties 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 Audit staff to ensuring coding is accurate by participating in planned and spot check audits in an on-going basis, feeding back results and areas of learning both informally and as part of the formal PBR process.
- Be responsible for conducting the PDRs for staff working in their Team (Clinical Coding Analyst), agreeing PDPs and feeding and coding training needs to the Coding training staff.
- 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 Coding Manager if any formal or informal action is required.
- To be responsible for monitoring and managing staff sickness absence via First Care reports, managing sickness absence in line with Trust policy where staff trigger the appropriate level, agreeing return to work plans and liaising with ATOS Occupational Health as required.
- Be Trust coding lead in a specific (specialist area) – for example, - . High Cost Drugs, Chemotherapy regimens working with senior staff to ensure knowledge is disseminated to other staff as appropriate.
- ACC qualified
- Knowledge of Cerner/Medicode
Pulse is an employment agency/employment business (as defined by the Conduct of Employment Agencies and Employment Businesses Regulations 2003) and is acting on behalf of its client in relation to this vacancy.