Detailed job description and main responsibilities

Work on own initiative to abstract and analyse complex clinical information from patient records including test results, discharge summaries, theatre notes and other information which may be stored locally within a specialty (e.g., ICR, Badger, Management System, PACS, ICE). Translate this information into a coded format in line with National Standards and Trust policies and procedures with a high degree of accuracy.

To enter the final encoded data onto the appropriate computer systems to meet essential Trust requirements for statutory information and financial reporting, ensuring Trust income is correct. This will require extended periods of concentration, and prolonged VDU use.

To provide coding cover in periods of absence on all specialties, maintaining a high level of accuracy whilst doing so.

To act as lead contact with designated specialties and communicate complex issues with medical staff on coding queries relating to diagnoses and operative procedures, using persuasive skills where necessary, in order to ensure accuracy and consistency of information.

Be a mentor for Clinical Coders, providing support, motivation, guidance, and training through coaching for that individual on all aspects of the role.

Work with the Clinical Coding Team Leaders to develop and implement training plans for Trainee Clinical Coders.

Organise daily workload efficiently so that personal coding targets are met and support the rest of the coding team in achieving high standards of coding completeness and accuracy within agreed time scales.

In the absence of the Coding Managers, ensure all work is distributed across the team, and organised evenly covering all coding duties, and supervise the work of more junior colleagues?

Participate in the maintenance of departmental records of local and national coding policies/standards in order to ensure consistency and accuracy throughout the department. Assist in development of local coding policies and implementing local variations to coding rules.

Participate in the audit process, working closely with the Deputy Manager and Manager. Ensure audits take into account both national and local coding policies and rules and take into account varying factors such as quality and availability of documentation at the time of Coding.

To review audit reports provided by an external company on potential coding issues and identify why these were not pick up when originally coded. Document the audit findings.

Implement all actions resulting from audit recommendations. Feedback findings of audits to the Manager and share lessons learnt with colleagues.

Assist in the implementation of new initiatives affecting clinical coding and participate in planning of changes to work practice.

Promote a learning environment in the workplace and take responsibility for self - development. Support others in achieving the ACC qualification.

Participate in ongoing formal training in accordance with national standards and Trust requirements in order to update and maintain skills and knowledge.

Promote and improve awareness of clinical coding, communicating to clinical and management staff the complex rules of coding and its financial effects.

Keep up to date with national changes in coding conventions and changes in medical terminology.

To monitor stock levels within the department and to place orders as required and in the absence of the department manager.