Senior Clinical CoderinEllandinEllandPUBLISHED TUE 18 FEB 2025

The Senior Clinical Coder is responsible for the extraction and analysis of complex clinical information from clinical documents/systems relating to a patient's episode in hospital. The Clinical Coder translates the medical terminology applying relevant national clinical coding standards into codes from Classifications used nationally and internationally and record these as a key component of the patient's clinical history. They will use judgement to translate complex cases where a procedure or diagnosis may not be readily codeable.

The post holder will have achieved the national qualification of Accredited Clinical Coder and will continue to contribute towards their own working plan and training on specialty workshops and refresher courses. The post holder is expected to support the Clinical Coding Team to meet high standards of accuracy, timeliness, and completeness of the Trusts Clinical Coded data. They will support the senior coding team in the development of the service in accordance with local requirements whilst adhering strictly to national directives.

• Analyse highly complex clinical terms from EPR and other clinical source systems using judgement where details may be complex or conflicting.
• Provide consistently recorded data to well defined national standards. The Clinical Coding Department uses the ICD10 and OPCS classifications to record all diagnoses and procedures for inpatient and day case admissions.
• Check data quality and record necessary amendments.
• To liaise with various staff throughout the trust to facilitate timely, complete and accurate clinical source documentation for coding.
• To have a proactive and positive approach in working with consultants and clinicians to ensure that information is sufficient for requirements in providing high quality coded data
• Support the Senior Clinical Coding team to ensure continuous improvement in the quality of clinical data used for clinical governance, commissioning, and health needs analysis.
• Provide complex specialist coding advice for financial and audit purposes
• Manage own workload, without direct supervision, to ensure all relevant inpatient episodes are coded within the agreed deadlines to enable a complete financial assessment to be made.
• Keep up to date with any changes to clinical coding standards and attend training.
• Use Trusts clinical systems to maintain coding accuracy and facilitate completion of all coding within the timescales specified to meet the Trusts Contractual targets.

About us

Job responsibilities

To abstract and analyse highly complex clinical terms from the Electronic PR and other clinical source systems using judgement where details may be complex or conflicting and provide consistently coded data to well defined national standards using ICD10 and OPCS classifications to record all diagnoses and procedures for inpatient and day case admissions.

Support the Senior Clinical Coding Team to deliver the agreed clinical coding service to meet the needs of Calderdale and Huddersfield NHS Foundation Trust. Works with clinical and operational staff to ensure information provided in clinical systems is of a high quality and enabling continuous improvement in the quality of clinical data used for clinical governance, commissioning, and health needs analysis

See job description for further details

Person Specification

Qualifications/Training

Essential

• Accredited Clinical Coder (ACC) Qualification (and attendance at Coding Refresher if ACC qualification more than 3 years ago)
• Educated to degree level or equivalent experience in the specialist field of Clinical Coding
• GCSE English, Maths and Science or equivalent A to C
• AMSPA or equivalent in Medical Terminology
• IT literate including use of internet for research
• Commitment to continuing professional development
• Willingness to complete the Clinical Coding Mandatory Standards Refresher Training Course and other Clinical Coding as required
• Willingness to attend CHFT in-house training

• Desirable

  • Working towards Clinical Coding Audit/Trainer qualification
  • Microsoft Office qualification or equivalent

  Knowledge, Experience and Expertise

  Essential

  • Experience of working in a Patient Services environment
  • Experience of Medical Terminology
  • NHS experience
  • Working as part of a team and supporting others
  • In-depth knowledge of ICD10 and OPCS
  • Extensive proven experience of coding all clinical specialities
  • Awareness of Freedom of Information Act
  • Able to demonstrate judgment skills to translate complex clinical diagnoses and procedures into accurate codes
  • Awareness of clinical terming and coding systems
  • High level of knowledge of medical terminology, anatomical and physiological terms
  • Understanding of Information Governance and confidentiality
  • Ability to prioritise activities according to deadlines
  • Excellent attention to detail and ability to work as part of a team
  • Advanced keyboard skills, use of VDU and inputting into a computer continuously
  • Appreciation of Data protection and patient confidentiality
  • The ability to prioritise activities and work to tight deadlines handling many different tasks at once
  • The ability to work under pressure and concentrate for long periods requiring accuracy and attention to detail
  • Awareness of NHS IM&T Strategy
  • Awareness of security standards associated with information systems
  • • The ability to use own initiative and manage workload
    • The ability to be thorough, accurate and reliable
    • Ability to be proactive and responsible
    • Maintenance of confidentiality
    • The ability to interpret clinical information whilst having an enquiring mind and being adaptable
    • Experience of working with different software systems in the NHS environment
    • Problem solving

    Desirable

    • Experience of mentoring other clinical coders
    • In-depth knowledge of HRGs and their role within coding
    • Ability to work across boundaries within THIS
    • Driving Licence and car owner

    Communication and Relationships

    Essential

    • The ability to communicate at all levels with tact and diplomacy
    • Excellent interpersonal and communication skills
    • Be able to communicate highly complex coding rules to coders and non-coders including clinical, admin and senior managers
    • Persuasive skills and able to deal with clinical teams and managers
    • Motivational skills
    • The ability to work as part of a team and on own