Job responsibilities
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.
