Clinical Coding Information Assurance Lead
NHS Jobs Bolton
Responsible for providing an advanced level of clinical coding within the Trust. This role involves coding complex medical records, ensuring the accurate translation of patient data into diagnostic and procedural codes using ICD-10 and OPCS4 classifications.
They will support clinical coding audits, mentor and train less experienced staff, and collaborate across departments to enhance the quality of clinical coding and improve data accuracy. This position requires a deep understanding of clinical terminology, coding standards, and healthcare systems to ensure the Trust meets both local and national coding standards and deadlines.
Main Responsibilities: Clinical Coding: Accurate Coding: Independently code a wide range of medical records from patient documentation (e.g., Electronic Patient Records (EPR), clinical systems, and paper records) into ICD-10 and OPCS4 codes, ensuring high levels of accuracy and alignment with national coding standards.
Complex Cases: Handle complex coding cases, including those involving multiple diagnoses, treatments, or procedures. Timeliness: Ensure all coding is completed within specified timeframes, meeting departmental deadlines. Query Resolution: Respond to and resolve coding queries raised by clinicians or other hospital staff, providing explanations of coding rules and guidelines as necessary.
Maintain High Standards: Work to consistently exceed the required quality standards for clinical coding, ensuring all audits meet "Standards Exceeded" criteria as per the DSPT. Audit and Quality Assurance: Conduct Coding Audits: Support coding audits, including the annual DSPT (Data Security and Protection Toolkit) Audit, to evaluate the accuracy and completeness of clinical coding.
Continuous Monitoring: Regularly check coding performance and identify areas of improvement to ensure coding standards are met or exceeded. Audit Recommendations: Address issues identified in audits, implementing corrective actions to improve coding accuracy and data quality.
Training and Development: Staff Mentorship: Mentor and provide training to junior coders, supporting their professional development and helping them improve coding accuracy. Deliver Training: Assist with delivering clinical coding training sessions for staff, including new starters, Trainee Clinical Coders, and other non-coding staff, ensuring they are familiar with coding processes, guidelines, and national standards.
Management and Support Functions: Workload Management: Support the Clinical Coding Manager in planning and managing the team's workload, ensuring the department meets its performance targets. Team Coordination: Assist in the coordination of the teams rota, annual leave, and other administrative duties related to team management.
Staff Recruitment Support: Assist with recruitment processes for new clinical coders, including shortlisting, conducting practical tests, and interviewing candidates. Continuous Improvement and Innovation: Policy Development: Contribute to the development and continuous improvement of clinical coding policies and procedures.
Best Practice Implementation: Share knowledge of best practices and contribute to the improvement of coding processes across the department. Feedback Systems: Help develop feedback systems for coders, clinicians, and managers to ensure ongoing improvement in documentation and coding quality.
Data Management and Reporting: Data Accuracy: Ensure the accuracy of coded data, which supports clinical governance, audits, financial reporting, and payment systems like PbR (Payment by Results) and HRG (Healthcare Resource Groups). Support Reporting: Provide accurate coded data for internal and external reporting requirements, including submissions for external audits, reviews, and governance processes.
Data Quality Assurance: Identify discrepancies or issues in clinical data and work with the Data Quality Team to resolve these issues promptly. Compliance and Confidentiality: Adherence to Standards: Ensure that all coding practices adhere to NHS guidelines, information governance policies, data protection laws (such as GDPR), and confidentiality requirements.
Confidentiality Maintenance: Safeguard patient and staff confidentiality, ensuring that sensitive information is handled securely and in line with Trust policies. Improvement Projects and Leadership: Lead Improvement Projects: Lead or contribute to clinical coding improvement projects, such as audits, training initiatives, and system upgrades, in collaboration with senior management and other departments.
Represent the Department: Represent the coding department at local and national coding forums, contributing expert knowledge and advice to relevant discussions or decision-making processes. Action Implementation: Act on recommendations from audits and performance reviews, working with the Senior Clinical Coding Management Team to implement changes across the department.
Skills and Qualifications: Essential Qualifications: National Clinical Coding Qualification (NCCQ) and Accredited Clinical Coder (ACC) status. Either holds or is working towards an advanced qualification, such as Approved Clinical Coding Auditor Status, Approved Clinical Coding Trainer Status, or a relevant managerial qualification.
Completion of mandatory training courses, including Clinical Coding Standards Refresher Course and Specialty Workshop Refreshers. Essential Experience: Proven experience in clinical coding, with a thorough understanding of ICD-10 and OPCS4 classifications.
Experience in conducting audits, mentoring staff, and providing training. In-depth knowledge of clinical terminology, anatomy, physiology, and medical procedures. Desirable Skills and Experience: Experience in leadership or supervisory roles within a clinical coding environment.
They will support clinical coding audits, mentor and train less experienced staff, and collaborate across departments to enhance the quality of clinical coding and improve data accuracy. This position requires a deep understanding of clinical terminology, coding standards, and healthcare systems to ensure the Trust meets both local and national coding standards and deadlines.
Main Responsibilities: Clinical Coding: Accurate Coding: Independently code a wide range of medical records from patient documentation (e.g., Electronic Patient Records (EPR), clinical systems, and paper records) into ICD-10 and OPCS4 codes, ensuring high levels of accuracy and alignment with national coding standards.
Complex Cases: Handle complex coding cases, including those involving multiple diagnoses, treatments, or procedures. Timeliness: Ensure all coding is completed within specified timeframes, meeting departmental deadlines. Query Resolution: Respond to and resolve coding queries raised by clinicians or other hospital staff, providing explanations of coding rules and guidelines as necessary.
Maintain High Standards: Work to consistently exceed the required quality standards for clinical coding, ensuring all audits meet "Standards Exceeded" criteria as per the DSPT. Audit and Quality Assurance: Conduct Coding Audits: Support coding audits, including the annual DSPT (Data Security and Protection Toolkit) Audit, to evaluate the accuracy and completeness of clinical coding.
Continuous Monitoring: Regularly check coding performance and identify areas of improvement to ensure coding standards are met or exceeded. Audit Recommendations: Address issues identified in audits, implementing corrective actions to improve coding accuracy and data quality.
Training and Development: Staff Mentorship: Mentor and provide training to junior coders, supporting their professional development and helping them improve coding accuracy. Deliver Training: Assist with delivering clinical coding training sessions for staff, including new starters, Trainee Clinical Coders, and other non-coding staff, ensuring they are familiar with coding processes, guidelines, and national standards.
Support Professional Development: Stay up to date with the latest coding standards, classifications, and national guidelines, and ensure personal knowledge is regularly refreshed through mandatory training courses. Collaboration and Stakeholder Engagement: Work with Clinical Teams: Liaise with clinicians, administrative staff, and other healthcare professionals to resolve complex coding queries, improve documentation practices, and ensure clinical records are complete and accurate for coding purposes.
Departmental Engagement: Collaborate with various departments to identify and address issues in documentation that could impact coding accuracy, such as electronic record updates or missing case notes. Coding Training for Clinicians: Provide education and guidance to clinicians about the importance of accurate documentation and its impact on clinical coding.Management and Support Functions: Workload Management: Support the Clinical Coding Manager in planning and managing the team's workload, ensuring the department meets its performance targets. Team Coordination: Assist in the coordination of the teams rota, annual leave, and other administrative duties related to team management.
Staff Recruitment Support: Assist with recruitment processes for new clinical coders, including shortlisting, conducting practical tests, and interviewing candidates. Continuous Improvement and Innovation: Policy Development: Contribute to the development and continuous improvement of clinical coding policies and procedures.
Best Practice Implementation: Share knowledge of best practices and contribute to the improvement of coding processes across the department. Feedback Systems: Help develop feedback systems for coders, clinicians, and managers to ensure ongoing improvement in documentation and coding quality.
Data Management and Reporting: Data Accuracy: Ensure the accuracy of coded data, which supports clinical governance, audits, financial reporting, and payment systems like PbR (Payment by Results) and HRG (Healthcare Resource Groups). Support Reporting: Provide accurate coded data for internal and external reporting requirements, including submissions for external audits, reviews, and governance processes.
Data Quality Assurance: Identify discrepancies or issues in clinical data and work with the Data Quality Team to resolve these issues promptly. Compliance and Confidentiality: Adherence to Standards: Ensure that all coding practices adhere to NHS guidelines, information governance policies, data protection laws (such as GDPR), and confidentiality requirements.
Confidentiality Maintenance: Safeguard patient and staff confidentiality, ensuring that sensitive information is handled securely and in line with Trust policies. Improvement Projects and Leadership: Lead Improvement Projects: Lead or contribute to clinical coding improvement projects, such as audits, training initiatives, and system upgrades, in collaboration with senior management and other departments.
Represent the Department: Represent the coding department at local and national coding forums, contributing expert knowledge and advice to relevant discussions or decision-making processes. Action Implementation: Act on recommendations from audits and performance reviews, working with the Senior Clinical Coding Management Team to implement changes across the department.
Skills and Qualifications: Essential Qualifications: National Clinical Coding Qualification (NCCQ) and Accredited Clinical Coder (ACC) status. Either holds or is working towards an advanced qualification, such as Approved Clinical Coding Auditor Status, Approved Clinical Coding Trainer Status, or a relevant managerial qualification.
Completion of mandatory training courses, including Clinical Coding Standards Refresher Course and Specialty Workshop Refreshers. Essential Experience: Proven experience in clinical coding, with a thorough understanding of ICD-10 and OPCS4 classifications.
Experience in conducting audits, mentoring staff, and providing training. In-depth knowledge of clinical terminology, anatomy, physiology, and medical procedures. Desirable Skills and Experience: Experience in leadership or supervisory roles within a clinical coding environment.
Experience with data quality and audit processes within the NHS or similar healthcare settings. Ability to work under pressure, meet deadlines, and manage a varied workload efficiently.
Bolton NHS Foundation TrustBolton (Greater Manchester)
supporting the Trust’s coding initiatives.
Compliance with Information Governance and Data Protection policies is essential, ensuring the safeguarding of patient and staff confidentiality.
Working for our organisation
Bolton NHS Foundation Trust...
Bolton NHS Foundation TrustBolton (Greater Manchester)
will stay updated on national standards and emerging coding technologies. You will ensure the accuracy of coded data for clinical governance, audits, and reporting, supporting the Trust’s coding initiatives.
Compliance with Information Governance and Data...
Government Recruitment ServiceSalford, 6 mi from Bolton (Greater Manchester)
is to protect the DBT's people, assets, and information from those who wish to damage it. We do this by building a diverse team with expert, generalist, and entry level roles to work together to solve the challenges we face. This mix allows us to develop talent...
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