Trainee Clinical Coder / Senior Clinical Coder / Coding Specialist
The post-holder is responsible for abstracting and analysing information from case notes; translating it accurately into diagnostic and operation/procedure codes, across all specialties in accordance with current coding classifications; enter the patient data on to the Trusts PAS system; deal with enquiries; liaise with clinicians; locate and collate missing source material e.g. missing case notes, histology. Appropriate clinical information from patient health records is translated into diagnoses and procedure codes in accordance with National Clinical Coding Standards - which accurately reflect the patients stay.
Confidentiality of all coded and other patient information is maintained at all times. A minimum of 5 GCSEs at Grade C / Grade 4 equivalent & above are required, including English and Maths, or equivalent qualification and/or experience. Knowledge of the International Statistical Classification of Diseases and Health Related problems, Revision 10 (ICD10), and the Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, Revision 4.9 (OPCS4) would be advantageous, as would knowledge of clinical terminology and anatomy and physiology.
Other skills Knowledge of NHS data systems relating to Inpatients and Day cases, Inpatient Waiting Lists, and some knowledge of Outpatients. Keyboard skills. Attention to detail. Ability to work to a high degree of accuracy within tight deadlines is essential.Effective interpersonal skills to liaise with Clinical and Administration staff on issues of coding, and the associated administrative processes.