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Detailed job description and main responsibilities

Job summary

• To accurately extract relevant clinical information from the Patient Health Care Record and to assign appropriate codes following established National Coding Guideline
  
  
• To interface with clinicians, healthcare workers, and other relevant personnel in order to ensure coding accuracy and integrity are maintained at the highest level

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• To mentor and support all junior staff

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Job responsibilities

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Communication and Team Working

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1. To seek guidance from Trust clinicians to address coding issues and discrepancies related to their specific specialities

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1. Assign correlation of data from electronic patient record to 3M Medicode software for data, service improvement and HRG gathering

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1. To promote among clinicians, health care workers and any other associated outside agency, awareness of the Clinical Coding role and its uses within the trust to raise the stature of Clinical Coding as the essence of professionalism

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1. Facilitate improved communication within the department and between other departments, clinicians, managers, ward staff and other personnel

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1. To interface with other Trusts, offices, and personnel in seeking ways, means, and ideas to improve the coding office processes

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Planning and Organising

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1. To assist the Team Manager in maintaining departmental performance with regard to quality and quantity by upholding agreed standards

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1. To assist the Team Manager in work allocation, supervision and planning tasks to all members of staff

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1. Monitor own performance against previously agreed objectives

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1. To support the team ensuring monthly targets are met

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1. Organise own day to day work task, completing priority coding foremost

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1. Operate own workload day to day

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Managing – People and Resources

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1. To take personal responsibility to ensure the correct usage of all resources provided to perform assigned tasks

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1. Assist the Team Manager in monitoring performance of junior members of staff

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1. To identify and participate in any cost improvement measures as required

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Training and Teaching

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1. To seek and attend in-house training, workshops, formal training, open discussions, and briefing from various expert sources in order to maintain coding proficiency

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1. To seek knowledge and experience levels required to maintain national Accredited Clinical Coder (ACC) status

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1. To be responsible for attaining and maintaining proficiency levels necessary to sustain coding data accuracy and integrity

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1. Attain and maintain proficiency levels in all tasks within the coding office and perform these duties as required

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1. Mentor junior members of staff in speciality coding

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1. Mentor junior members of staff in coding direction and assistance

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1. Assist the Team Manager in the training and development of junior members of staff as required

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1. To maintain IT knowledge and 3M knowledge

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1. To maintain medical terminology and coding conventions and to increase skill in long term development

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Policy, Service, Research Development

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1. Participate in audit and monitoring of standards

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1. To participate in the development of an evidenced-based and patient focused service

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1. To be responsible for increasing their own professional research knowledge by promoting a questioning and analytical approach to coding

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1. Adhere to local coding office Policies and Procedures, conforming to National Standards as established by the Clinical Coding Team Manager

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1. Ensure correct procedures are adhered to relating to telephone calls into department and take appropriate action as necessary

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1. To work within an overall framework of Clinical Governance

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1. To support the Team Manager in the implementation of Trust Policies such as Risk Assessment and Incident Reporting management

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1. Comply with patient confidentiality and GDPR at all times

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1. Implement agreed Local Polices and Clinical Coding Guidelines, update training materials when changes require

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Administration

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1. To attend discussions, meetings, and functions that have a direct bearing on the clinical coding process, as required. Ensuring coding processes are not compromised

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1. Develop knowledge of the correct procedures and use of the Individual Performance Review (IPR) system

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1. To uphold highest levels of efficiency relating to the correct usage of the eCare, 3M Medicode, ICE, Evolve and any other data storage systems required to maintain standards

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1. Frequent prolonged effort for workload on a computer

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1. Frequent indirect exposure to emotional circumstances

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1. Constant requirement for prolonged concentration and sitting for long periods at workstation.

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Health, Safety and Security

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1. Use and encourage others to be familiar with the personal security systems within the workplace, according to practice guidelines

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1. To initiate the emergency alarm when required if assistance is required for staff and patient safety

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1. Identify the risks involved in work activities and undertake them in a way that minimises risks

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1. Work in line with Health and Safety policies and procedures within the workplace

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1. Uses the trust incident reporting system to report any issues that may affect the working environment.

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Personal Development/Clinical & Professional

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1. To at all times strive to use correctly the following guidelines: International Statistical Classification of Diseases and Related Health Problems (ICD-10) and Office of Population Censuses and Surveys (OPCS-4) within the Trust

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1. Maintain National Standards established by the NHS Digital National Clinical Coding Standard Reference books

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1. To support the Trust in complying with National Standards, for example CNST, Controls Assurance and National Clinical Coding Standards

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1. Judgement for all complex training factors in presentation and feedback scenarios

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1. To process and codify patients medical records and any other relevant documentation