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Clinical Coder

  • Job reference: clncoder1
  • Location: Ipswich, Suffolk
  • Job type: Temporary
  • Area of Expertise: IT
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Job description: Job Title: Clinical Coder
Location: Ipswich or Colchester
Contract: 6 months ongoing
Band: 5


OVERVIEW OF RESPONSIBILITIES

*To abstract and analyse complex clinical information from patient records and translate this into a coded format in line with National Standards. To have a high level of knowledge of Medical Terminology and Anatomy and Physiology.
*To enter the final encoded data onto the appropriate computer systems to meet essential Trust requirements for statutory information and payment flows.
*The post holder will work as part of a team of experienced trained and trainee staff and the job will involve rotation between duties working on all specialities.
*Deal with enquiries from all parts of the hospital.
*Locate source documents; read histology, cytology and radiology reports. Analyse complex medical information from paper documents and via other computer systems.
*Ensure that patient records are processed in the correct manner and tracked to appropriate destinations using the computer tracking system.
*Act as mentor and assist in the education of less experienced coders.
*To be aware of wider information and patient administration service systems.
*To ensure that computer and paper records are passed for remedial action or processed in the correct manner.

SPECIFIC RESPONSIBILITIES

*To convert diagnoses and operative procedures assigned to patients by medical staff into a coded format using the International Statistical Classification of Diseases (ICD10) and the Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (OPCS4), in order to provide high quality coded clinical data relating to diagnoses, operative procedures and derived HRGs.
* To collect the necessary medical information via hospital personnel, information systems and case notes for coding to be completed within agreed time limits (currently within 3 days of patient discharge) and to identify and contribute to the solution of problems or situations that obstruct the timely coding of patient records.
*To abstract and analyse complex clinical records to determine appropriate clinical coding. This will involve using own knowledge and judgement to translate complex cases.
*To act as lead contact with designated specialities and communicate complex issues with medical and non medical on coding queries relating to diagnoses and operative procedures in order to ensure accuracy and consistency of information
*To attend clinical and management meetings to discuss complex coding rules and guidelines and answer questions with regard to coding, thus raising awareness of the importance of clinical coding.
*To attend Theatre sessions to discuss and agree procedure coding with Surgeons and to input the resulting coded information on to the relevant electronic system.
*To identify and implement new procedures to ensure that all clinical data is fully documented by clinicians and is captured during the clinical coding process.
*To develop, in conjunction with the senior team, coding standards, and maintain on-going monitoring and audit procedures to ensure that coding is timely, complete, accurate and of a consistent high quality to meet the needs of the Trust.
*To attend seminars and training courses in order to receive and interpret clinical coding updates and effectively communicate these to all necessary staff.
*To ensure compliance with relevant legislation and Trust policy in areas of Health and Safety, Confidentiality and Data Protection.
*To undertake any other duties as may be agreed.

This job profile is not a definitive or exhaustive list of responsibilities but identifies the key responsibilities and tasks of the post holder. The specific objectives of the post holder will be subject to review as part of the Appraisal and Development Plan process.