Clinical Coding Auditor
Job Purpose: The post holder will take the lead role for internal Clinical Coding audit, to ensure the Trust meets national standards for Clinical Coding and adheres to the Clinical Coding audit policy. In conjunction with the Clinical Coding Manager will develop and implement an ongoing programme of Clinical Coding audits and training throughout the Trust to continuously improve data quality and secure Trust income under Payment by Results.
Will act as Lead Clinical Coder and will assist all coders with complex coding queries and provide expert advice in other departments on coding issues. Will be responsible for the monitoring and ensuring the completion of the Trusts Clinical Coding backlog The post holder will deputise for the Clinical Coding Manager.
Responsibilities: Main duties 1. To carry out internal audit work on the Trusts Clinical Coding in accordance to Clinical Coding audit policy and procedures. Adhering to national standards in Clinical Coding using the International Classification of Diseases ICD-10 volumes 1-3 and operative procedures in accordance to the Office of Population Census OPCS-4.
2. Prepare and present both coding and clinical audit reports, ensure close working and engagement for the clinical coding data validation process 3. To ensure continual improvement of clinical coded information within the Trust through systemic audit and quality assurance procedures, in compliance with national standards, classification rules and conventions.
4. Any training issues identified in audit to be addressed promptly 5. To liaise with Clinicians and Directorates as a coding specialist and to communicate complex coding rules to medical, clinical and administrative staff in order to establish the accurate diagnosis and procedure codes for each speciality.
6. To plan and organise both short and long term strategic objectives for clinical coding to enable the Trust respond successfully to changing internal and external demands 7. To facilitate and support the Clinical Coding team so as to input onto the hospital patient administration system is accurate and complete coded information within the designated timescales in order to support the information requirements and commissioning of the Trust 8.
To be responsible for managing and responding to all coding queries raised by coders and Trust staff. 9. To conduct regular meetings with Clinical coding Manager, Data Quality Manager to develop and implement action plans arising from internal and external reviews, audits, validation exercises, Data Set Change Notices (DSCNs) and other related activities/requirements.
10. To assist with yearly external audit which is an essential requirement of the NHS Connecting for Health Data Quality Framework. 11. Deputise for Clinical Coding Manager whenever necessary. Compliance Daily Operations/Planning To record data in manual and computerised systems in accordance with agreed policies and procedures To adhere to Trust policies regarding confidentiality and information security To carry out any other duties commensurate with the grade of this job.
The duties defined in this job description are not definitive and may be subject to future amendments following appropriate consultation Standard Clauses: The purpose of this post should remain constant, but the duties and responsibilities may vary over time within the overall role and level of the post.
The post holder may from time to time be asked to undertake other reasonable duties. Any such changes will be made in discussion with the post holder in the light of service needs. Competence: The post holder is responsible for limiting his/her actions to those which s/he feels competent to undertake.
If the post holder has any doubts as to his or her competence during the course of his/her duties then s/he should immediately speak to their line manager or supervisor. Codes of conduct: All employees of the Trust who are required to be registered with a professional body, to enable them to practise within their profession, are required to comply with their code of conduct and requirements of their professional registration.
Staffs that are not required to be registered with a professional body are required to comply with the Trusts codes of conduct. Confidentiality: The post holder must maintain confidentiality, security and integrity of information relating to patients, staff and other Health Service business.
Records Management: All employees of the Trust are legally responsible for all records that they gather, create or use as part of their work within the Trust (including patient, financial, personnel and administrative), whether paper or computer based.
All such records are considered public records and all employees have a legal duty of confidence to service users. Employees should consult their manager if they have any doubt as to the correct management of records with which they work. Health and Safety: Employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act (1974) and the Manual Handling Operations Regulations (1992) and all relevant Trust Health and Safety Policies and Guidance.
This ensures that the agreed safety procedures are carried out to maintain a safe environment for employees, patients and visitors to the Trust. Infection Control: Employees must accept personal responsibility and accountability for Infection Prevention and Control practice.
Employees should ensure they are familiar with, and comply with, all relevant Infection Control policies for minimising the risk of avoidable Health Care Associated Infection. All Employees must undertake annual mandatory updates in Infection Control.
Non Smoking Policy: The Trusts approach to smoking is in line with the governments on-going initiatives for an eventual smoke-free environment. It aims to adhere to the Worcestershire Health Community Campaign to help Worcestershire stop smoking.
A no smoking environment policy exists within all Trust premises including entrances and exits to hospital buildings and on other Trust property (with the exception of staff resident in staffresidences, as these are the homes of staff). In June 2014 a ban was implanted which meant staff, contractors and volunteers were no longer permitted to smoke in any of the hospital grounds, including car parks.
Further to this, The Alexandra, Kidderminster and Worcestershire Royal Hospitals, have all become smoke free to all patients and visitors as of 17 June 2015. This means that, as well as staff, members of the public, patients and visitors are not allowed to smoke in any of the acute hospital grounds, including car parks.
Risk Management: It is a standard element of the role and responsibility of all employees of the Trust that they fulfil a proactive role towards the management of risk in all of their actions. This entails the risk assessment of all situations, taking appropriate actions, and reporting all incidents, near misses, and hazards promptly.
It is a contractual obligation that all employees must co-operate with any investigations undertaken. Children and vulnerable adults: You have a responsibility for promoting and safeguarding the welfare of the children/young people/vulnerable adults that you come into contact with or are responsible for in your job role and sphere of competence.
Disclosure and Barring Service: The Trust aims to promote equality of opportunity for all, with the right mix of talent, skills and potential. Criminal records will be taken into account for recruitment purposes, only when the conviction is relevant.
As the Trust meets the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974, all applicants who are offered employment will be subject to a criminal record check from the Disclosure and Barring Service before the appointment is confirmed.
This will include details of cautions, reprimands or final warnings, as well as convictions. Potholders may periodically be asked to undertake a re-check. The Trust is legally required to check all staff against the Disclosures and Barring Services Childrens and Vulnerable Adults barring lists if they engage in what is defined as Regulated Activity or Controlled Activity: Regulated Activity is defined as working closely with children or vulnerable adults, paid or unpaid, on a frequent or intensive basis.
Controlled activity is work that provides opportunities for contact with children or vulnerable adults, or their records. This includes caterers, cleaners, administrators, contractors, maintenance workers and their managers and supervisors. Equality and Diversity: The Trust promotes policies and practices that challenge discrimination, promote equality, respect individual needs, preferences and choices, and protects human rights.
The Trust has a clear commitment to equality for all in employment practices based on an applicants ability, skills and aptitude for the post. A range of equality & diversity policy initiatives are in place and all successful applicants are expected to familiarise themselves with these.
It is therefore the duty of every employee to comply with the detail and spirit of these policies and the law at all times. Any issues or concerns you have should be taken up with your manager or the human resource team as soon as possible.
Will act as Lead Clinical Coder and will assist all coders with complex coding queries and provide expert advice in other departments on coding issues. Will be responsible for the monitoring and ensuring the completion of the Trusts Clinical Coding backlog The post holder will deputise for the Clinical Coding Manager.
Responsibilities: Main duties 1. To carry out internal audit work on the Trusts Clinical Coding in accordance to Clinical Coding audit policy and procedures. Adhering to national standards in Clinical Coding using the International Classification of Diseases ICD-10 volumes 1-3 and operative procedures in accordance to the Office of Population Census OPCS-4.
2. Prepare and present both coding and clinical audit reports, ensure close working and engagement for the clinical coding data validation process 3. To ensure continual improvement of clinical coded information within the Trust through systemic audit and quality assurance procedures, in compliance with national standards, classification rules and conventions.
4. Any training issues identified in audit to be addressed promptly 5. To liaise with Clinicians and Directorates as a coding specialist and to communicate complex coding rules to medical, clinical and administrative staff in order to establish the accurate diagnosis and procedure codes for each speciality.
6. To plan and organise both short and long term strategic objectives for clinical coding to enable the Trust respond successfully to changing internal and external demands 7. To facilitate and support the Clinical Coding team so as to input onto the hospital patient administration system is accurate and complete coded information within the designated timescales in order to support the information requirements and commissioning of the Trust 8.
To be responsible for managing and responding to all coding queries raised by coders and Trust staff. 9. To conduct regular meetings with Clinical coding Manager, Data Quality Manager to develop and implement action plans arising from internal and external reviews, audits, validation exercises, Data Set Change Notices (DSCNs) and other related activities/requirements.
10. To assist with yearly external audit which is an essential requirement of the NHS Connecting for Health Data Quality Framework. 11. Deputise for Clinical Coding Manager whenever necessary. Compliance Daily Operations/Planning To record data in manual and computerised systems in accordance with agreed policies and procedures To adhere to Trust policies regarding confidentiality and information security To carry out any other duties commensurate with the grade of this job.
The duties defined in this job description are not definitive and may be subject to future amendments following appropriate consultation Standard Clauses: The purpose of this post should remain constant, but the duties and responsibilities may vary over time within the overall role and level of the post.
The post holder may from time to time be asked to undertake other reasonable duties. Any such changes will be made in discussion with the post holder in the light of service needs. Competence: The post holder is responsible for limiting his/her actions to those which s/he feels competent to undertake.
If the post holder has any doubts as to his or her competence during the course of his/her duties then s/he should immediately speak to their line manager or supervisor. Codes of conduct: All employees of the Trust who are required to be registered with a professional body, to enable them to practise within their profession, are required to comply with their code of conduct and requirements of their professional registration.
Staffs that are not required to be registered with a professional body are required to comply with the Trusts codes of conduct. Confidentiality: The post holder must maintain confidentiality, security and integrity of information relating to patients, staff and other Health Service business.
Records Management: All employees of the Trust are legally responsible for all records that they gather, create or use as part of their work within the Trust (including patient, financial, personnel and administrative), whether paper or computer based.
All such records are considered public records and all employees have a legal duty of confidence to service users. Employees should consult their manager if they have any doubt as to the correct management of records with which they work. Health and Safety: Employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act (1974) and the Manual Handling Operations Regulations (1992) and all relevant Trust Health and Safety Policies and Guidance.
This ensures that the agreed safety procedures are carried out to maintain a safe environment for employees, patients and visitors to the Trust. Infection Control: Employees must accept personal responsibility and accountability for Infection Prevention and Control practice.
Employees should ensure they are familiar with, and comply with, all relevant Infection Control policies for minimising the risk of avoidable Health Care Associated Infection. All Employees must undertake annual mandatory updates in Infection Control.
Non Smoking Policy: The Trusts approach to smoking is in line with the governments on-going initiatives for an eventual smoke-free environment. It aims to adhere to the Worcestershire Health Community Campaign to help Worcestershire stop smoking.
A no smoking environment policy exists within all Trust premises including entrances and exits to hospital buildings and on other Trust property (with the exception of staff resident in staffresidences, as these are the homes of staff). In June 2014 a ban was implanted which meant staff, contractors and volunteers were no longer permitted to smoke in any of the hospital grounds, including car parks.
Further to this, The Alexandra, Kidderminster and Worcestershire Royal Hospitals, have all become smoke free to all patients and visitors as of 17 June 2015. This means that, as well as staff, members of the public, patients and visitors are not allowed to smoke in any of the acute hospital grounds, including car parks.
Risk Management: It is a standard element of the role and responsibility of all employees of the Trust that they fulfil a proactive role towards the management of risk in all of their actions. This entails the risk assessment of all situations, taking appropriate actions, and reporting all incidents, near misses, and hazards promptly.
It is a contractual obligation that all employees must co-operate with any investigations undertaken. Children and vulnerable adults: You have a responsibility for promoting and safeguarding the welfare of the children/young people/vulnerable adults that you come into contact with or are responsible for in your job role and sphere of competence.
Disclosure and Barring Service: The Trust aims to promote equality of opportunity for all, with the right mix of talent, skills and potential. Criminal records will be taken into account for recruitment purposes, only when the conviction is relevant.
As the Trust meets the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974, all applicants who are offered employment will be subject to a criminal record check from the Disclosure and Barring Service before the appointment is confirmed.
This will include details of cautions, reprimands or final warnings, as well as convictions. Potholders may periodically be asked to undertake a re-check. The Trust is legally required to check all staff against the Disclosures and Barring Services Childrens and Vulnerable Adults barring lists if they engage in what is defined as Regulated Activity or Controlled Activity: Regulated Activity is defined as working closely with children or vulnerable adults, paid or unpaid, on a frequent or intensive basis.
Controlled activity is work that provides opportunities for contact with children or vulnerable adults, or their records. This includes caterers, cleaners, administrators, contractors, maintenance workers and their managers and supervisors. Equality and Diversity: The Trust promotes policies and practices that challenge discrimination, promote equality, respect individual needs, preferences and choices, and protects human rights.
The Trust has a clear commitment to equality for all in employment practices based on an applicants ability, skills and aptitude for the post. A range of equality & diversity policy initiatives are in place and all successful applicants are expected to familiarise themselves with these.
It is therefore the duty of every employee to comply with the detail and spirit of these policies and the law at all times. Any issues or concerns you have should be taken up with your manager or the human resource team as soon as possible.
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