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Detailed job description and main responsibilities

1. Communication and Technical Skills

• Ensure the full range of guidance and rules relating to the usage of ICD10 and OPCS4 are documented, and provide guidance throughout the relevant Divisions in their use and interpretation. Work with the Clinical Coding Team Manager and Clinical Coding Trainer in provision of training and support to more junior staff in particular those areas of specialism.
• Ensure the maximisation of achieving 100% data quality and completeness is ongoing towards deadline targets. Understand the importance of complex Payment by Results (PbR) rules and HRGs in the above context and assist team members in the workings of this.
• Assist the audit team in the engagement of external complex audits when required and support and assist in a continuous Trust internal audit programme, when appropriate, liaising with senior clinicians in reviewing the information provided for clinical coding within the case-notes, and information recorded on systems.
• Assist the Clinical Coding Team Manager in the scrutiny of data capture where it impacts on PAS and coding and support quality assurance of this where relevant.
• Promoting coder/clinician engagement.
• Understand the impact of coded data on the business aspects of the Trust, and thus be able to provide the information and advice to all health professionals and administrative staff of the nature and complexity of clinical coding and its purposes in areas such as patient care, clinical and information governance, clinical audit, finance, budgeting, data quality and research.

2. Policy and Process

• To provide specialist knowledge in areas of expertise to coding teams, including auditors and managers. To access, research and reference all appropriate clinical documentation in complex areas and feedback accordingly.
• Ensure all relevant coding staff are trained in the timely collection and return of case-notes, and/or discharge information required for coding. Ensure coders can provide a flexible coding service for areas responsible and understand the flow of patient discharge information through the Trust information systems.
• Advise the Clinical Coding Team Manager on organisation and process in areas of expertise and assist in the provision of cover for colleagues.
• To liaise closely with clinicians to validate clinical information to ensure the quality of coded data for specialist services and areas of high complexity using expertise and knowledge within given area.

3. Training and Quality Assurance

• Ensure complex national rules and conventions are understood and advise the Clinical Coding Team Manager on subsequent appropriate attendance at workshops both internally and externally as required.
• Ensure compliance and expertise in the use of coding encoder system e.g. Medicode and all clinical information feeder systems such as Evolve, CMiS, BadegerNet.
• Assist in resolving data quality issues relating to data inconsistency impacting on the accuracy of coding and ensure that the errors are reported and corrected as necessary.
• Develop and assist the coding management and team in the streamlining of more efficient processes that assist the collection of accurate data, to do this via clinical engagement, liaison with senior managers and staff within the divisions.
• Advise on changes of process and service delivery within the divisions and alert the management team as and where appropriate.
• Proactively and regularly report the status and performance of the uncoded position within the areas of responsibility.
• Assist the senior managers in the presentation of complex coded data and advise in any audits undertaken in specialised areas; assist in the subsequent implementation of error correction and process enhancement that arise from this process.
• Assist the management team in areas of expertise where clinical input and research has guided.
• Assist in training and monitoring of new staff in both technical coding and process.

4. Other duties

• Provide cover for colleagues as appropriate.
• Attend meetings on behalf of the senior coding managers internally and externally when required.
• Undertake any other duties requested as appropriate to the banding.
• Be aware of and promote data confidentiality issues within the Trust.
• Promote and be an activist on own initiative if required in the quest for bringing the awareness of clinical coding, its processes and uses, to all relevant staff within the Trust and beyond wherever necessary.
• Participate in designated areas in the monthly achievement of deadline targets, assuring a high standard in completeness, timeliness and accuracy. Ensure own targets are met.
• Take a lead in the development of process in specialised areas and advise the senior coding management on best practice in specialised areas
• Participate in coder/clinician MDTs - validation of clinical information and coded data in areas of complexity and high cost which impact on national outcomes, indicators, Trust reputation and income.