Job overview

Would you like to be part of a successful team committed to providing in-depth and accurate clinical information?

The principal responsibilities of a Clinical Coder involve accurately extracting diagnoses and procedures from the health records, translating it into codes using the ICD-10 and OPCS-4 classifications and inputting them onto the Patient Administration System using encoding software.

You will follow all National Clinical Coding Standards to produce data that can be tabulated, aggregated and sorted for statistical analysis.

This is a remote position working from home however there may be a requirement to come on site on occasion. 

Main duties of the job

Identify in the electronic patient record what clinical information needs to be collected and to correctly assign clinical codes to diagnoses and procedures in line with current clinical coding national standards. 

Attend computer training on the EPIC hospital computer system in relation to clinical coding. This will enable the user to navigate the data fields in Epic required to extract data for clinical coding use and the completion of clinical coding.

Attend dedicated clinical coding encoder training sessions which will enable the user to be able to navigate the MEDICODE software successfully and gain full use of this system.

Undertake local and national clinical coding training programs held either internally or externally as required.

Ensure all coding is completed in a timely fashion in line with Trust and billing requirements. 

Report to the Clinical Coding Team Leader any discrepancies in clinical information contained in the medical record that contradicts clinical coding guidelines.

Promote and adhere to clinical coding policies and procedures and national guidelines as laid down in the Data Quality Review and the National Classifications Service.  Maintain these documents as and when new guidelines are issued.

Carry the on-call Medical Records Major Incident bleep as per rota.  The week on call  is for 24 hours, 7 days a week.  This would entail being available at short notice in the event of a Major Incident.

Working for our organisation

Our Trust

Cambridge University Hospitals (CUH) NHS Foundation Trust comprises Addenbrooke’s Hospital and the Rosie Hospital in Cambridge. With over 13,000 staff and over 1100 beds the priorities of the Trust focus on a quality service which is all about people – patients, staff and partners. Recognised as providing ‘outstanding’ care to our patients and rated ‘Good’ overall by the Care Quality Commissioner, is testament to the skill and dedication of the people who work here. CUH’s values – Together - Safe, Kind, Excellent – are at the heart of patient care, defining the way all staff work and behave. The Trust provides accessible high-quality healthcare for the local people of Cambridge, together with specialist services, dealing with rare or complex conditions for a regional, national and international population.

CUH is committed to promoting a diverse and inclusive community - a place where we can all be ourselves. We value our differences and fully advocate and support an inclusive working environment where every individual can fulfil their potential. We want to ensure our people are truly representative of all the communities that we serve. We welcome applications for all positions in the organisation irrespective of people’s age, disability, ethnicity, race, nationality, gender identity, sex, sexual orientation, religion or belief, marriage and civil partnership status, or pregnancy and maternity status or social economic background.