Clinical Coding Information Assurance Lead | Bolton NHS Foundation Trust

We are seeking a skilled Clinical Coder to join our team and advance their career. The successful candidate will play a key role in delivering a high-quality coding service across the Trust. The ideal candidate will hold the National Clinical Coding Qualification (NCCQ) and maintain Accredited Clinical Coder (ACC) status, with qualifications or an interest in obtaining qualifications in Auditing, Management, or Training. This position involves ensuring accurate and timely coding, resolving queries with clinicians, and managing complex cases across various specialties. The role also includes involvement with the Clinical Coding Management Team to plan and develop coding operations, audits, and training programs. The candidate will lead clinical coding improvement projects, collaborating with clinical and non-clinical departments to enhance documentation, data quality, and system requirements. Key duties include engaging with clinicians, supporting audits, assisting with coding training, and ensuring compliance with national standards and local policies. The role will also contribute to the development of new coding practices to maintain high standards of documentation and data quality. The ideal candidate will be proactive, detail-oriented, and possess excellent communication and leadership skills, with a commitment to continuous professional development. If you are motivated and experienced in clinical coding, we would love to hear from you. The role involves accurately abstracting, analyzing, and translating medical records into diagnostic and procedural codes using ICD-10 and OPCS4. You will ensure the timely and precise completion of clinical coding tasks, resolve coding queries with clinicians and staff, and address discrepancies identified during audits. Maintaining high standards of coding accuracy and consistently exceeding performance expectations is key. In addition to coding, you will assist in developing and delivering training programs, mentoring less experienced coders, and ensuring adherence to national standards. You will collaborate with clinical and non-clinical departments to improve documentation and coding accuracy. You will lead clinical coding improvement projects, working with teams to address system requirements and resolve documentation issues. You will support the planning, development, and management of coding operations, audits, and training schedules while ensuring efficient staff workload management. Contributing to the development of coding policies and procedures, you 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 Protection policies is essential, ensuring the safeguarding of patient and staff confidentiality. Bolton NHS Foundation Trust is an integrated care organisation. Royal Bolton Hospital (RBH) has approximately 700 beds and a turnover of £320m. The hospital is one of the busiest hospitals in Greater Manchester for urgent care and is also a regional 'supercentre' for maternity services, babies and children. As an integrated organisation we also provide care and support in the community at over 20 health centres and clinics, including the Bolton One complex in the town centre, as well as services such as district and school nursing. We serve a population of around 270,000 and employ approximately 5,300 staff. As mentioned earlier in this advert we strive to ensure that our staff can be the best they can be in their role, and we will create a development plan based on your individual needs. We ensure that our staff have regular FABB (For a Better Bolton) catch-up discussions with their manager and our VOICE Values clearly set out what we expect from all our staff whilst in work. Ultimately everything we do in the Trust has patient care at its heart, and your role as Clinical Coder will be so important in ensuring our patients get the best possible care. 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: 1.
• 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 team's 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.
  
  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., Disability Confident
About Disability Confident A Disability Confident employer will generally offer an interview to any applicant that declares they have a disability and meets the minimum criteria for the job as defined by the employer. It is important to note that in certain recruitment situations such as high-volume, seasonal and high-peak times, the employer may wish to limit the overall numbers of interviews offered to both disabled people and non-disabled people. For more details please go to Disability Confident.