Bedfordshire Hospitals NHS Foundation Trust
Job Summary
Must have Clinical Coding experience.
The post holder will provide an effective, accurate, timely, and consistent clinical coding service to the Trust and ensure all coding expectations are achieved, assisting in business intelligence outcomes and audits where appropriate.
Main duties of the job
- You will be expected to promote continuous improvement in data quality by keeping abreast of development and innovations in the medical, surgical, and coding disciplines. This role forms a key member of the data quality team, which aims to provide credible, accurate, complete, and timely data for the Trust.
- To review deceased patients and maintain higher SHMI performance for Bedfordshire Hospitals;
- To be proficient in the Trust’s many IT systems, including iPM, Viper, Medicode, ICE, Clinical Correspondence, MediViewer/Evolve (for ERDMS) and the Clinical Income Dashboard system;
- To review, on an on-going basis, clinical coding standards adopted within the Trust and to ensure by personal monitoring and peer review that these standards are being achieved by all coding staff;
- To liaise with other disciplines as required regarding data clarification, in order to support data quality;
- To have a comprehensive understanding of the Hospital Administrative systems to validate and correct errors, to ensure patient information is recorded accurately to support Information, Clinical Governance and Data Quality standards;
- To investigate, and correct complex clinical coding data rejected or queried by recipient information systems and advise the Data Standards Manager of such problems that could impact on Trust Performance.
About us
Bedfordshire Hospitals NHS Foundation Trust provides hospital services to a growing population of around 700,000 people living across Bedfordshire and the surrounding areas across two busy hospital sites in Bedford and Luton. Both hospital sites offer key services such as A&E, Obstetrics-led Maternity and Paediatrics. You will be joining a friendly, high performing Trust committed to ensuring the health and wellbeing of staff. As one of the largest NHS Trusts in our region you will have access to a programme of high quality training and development to help you grow your career. The Trust continues to be committed to delivering the best patient care using the best clinical knowledge and technology available.
Our values
We not only recruit based on qualifications and experience – we recruit individuals who demonstrate the behaviours which underpin our Trusts core values. We achieve this by using values based recruitment. We are dedicated to making our recruitment practices as inclusive as possible for everyone, we are committed to promoting equality and diversity, and creating a culture that values differences.
Job description
Job responsibilities
- To abstract and analyse complex information in the patients case notes or other source of documents and translate the medical terminology into clinical codes to the provisions of ICD-10 and OPCS-4 and Clinical Coding Manual, and to input the coded information on to the organizations clinical information system.
- To maintain national coding standards and adhere to national and international conventions to assign uniform codes, which represent a complete picture of the patients hospital stay.
- In accordance with expertise and knowledge gained through all training/educational processes, code to profession standards and conventions, and to ensure the high quality clinical coded data are provided with agreed time scales. This will require focus, motivational negotiation, and judgement.
- To be able to work under pressure maintaining accuracy especially around monthly closedown and the refresh period.
- To check the accuracy of admissions, transfer and discharge details in the patients medical record and to identify errors on the clinical information system.
- To answer Clinical Commissioning Group challenges in code assignment in a timely manner.
- Coding business analysts are required to create and maintain strong stakeholder engagement with Consultants and their clinical teams to ensure quality and depth of clinical coding is achieved. In order to achieve this they are required to communicate complex coding rules to various medical, clinical and administrative staff at all levels. Communication can be via telephone, in person, written, or by email.
- The ability to challenge, question and clarify by reasonable argument the adherence to national standards relating to clinical coding.
- To act as mentor to less experienced coding staff in understanding clinical coding rules. PbR and HRG (Healthcare Resource Groups), therefore having a sound knowledge of these processes themselves.
- To manage and prioritise own workload for designated areas within the department.
- To be proficient in the Trusts many IT systems, including iPM, ICE, Clinical Correspondence, Evolve (for ERDMS) and the Clinical Income Dashboard system.
- To access the Trust histopathological database (ICE) to extract the relevant information when assigning appropriate clinical codes.
- To liaise and attend meetings with clinicians and other medical staff on a regular basis to ensure that defined data quality standards are met, and maintain an ongoing expertise in order to discuss and validate complex clinical data and procedures with clinicians.
- 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 governance, clinical audit, finance, budgeting, data quality and research.
- To maintain a portfolio of evidence and professional accreditation through attendance and participation in ongoing internal and external training programmes; continuously updating comprehensive knowledge and understanding of medical terminology, anatomy, and physiology and its applications to clinical coding.
- To work as part of the team to supervise and support the training of new and less experienced coders; providing cover for colleagues as and when required; assisting with regular internal audits of clinical coding and in the customisation of the coding process (systems and procedures) to further the efficiency within the Trust with awareness of local agreed variations to coding rules on proposed changes, as well as report to the Clinical Coding Manager any contradictions to national guidelines.
- Maintain a flexible attitude and response to change in job content or organisation in order to maintain or improve the quality of service provided to patients, the Trust, and to other customers.
- To visit hospital wards and other departments as necessary to view source documents (case notes) required to complete coding; to collect source document sheets (e.g. discharge summaries); to take reasonable steps to chase up outstanding source data. Source documents will increasingly include electronic records.
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