Role Overview
We are seeking a highly skilled and detail-oriented Clinical Coder to accurately review, interpret, and translate patient clinical records into standardized diagnosis and procedure codes using ICD-10 and OPCS-4 classification systems. The successful candidate will play a critical role in ensuring the accuracy, completeness, and integrity of clinical data that supports healthcare reporting, reimbursement, quality improvement initiatives, clinical research, and operational decision-making.
The role requires strong knowledge of medical terminology, anatomy and physiology, clinical coding standards, and the ability to work independently while maintaining high levels of coding quality and productivity.
Key Responsibilities
- Review and analyse patient records to accurately identify and abstract diagnoses, co-morbidities, complications and procedures relevant to each inpatient episode.
- Assign accurate ICD-10 and OPCS-4 codes in accordance with national clinical coding standards, conventions and guidelines.
- Code complex clinical specialties and deceased patient records, liaising with clinicians where required to ensure accuracy and completeness.
- Maintain high standards of coding quality and productivity, contributing to the delivery of timely and reliable clinical data.
- Provide expert advice on complex coding issues, explaining coding decisions and rationale to clinical, medical and administrative staff.
- Collaborate with clinicians to clarify diagnoses, procedures and emerging clinical practices to support accurate code assignment.
- Share specialist knowledge and provide support, guidance and technical advice to colleagues within the Clinical Coding team.
- Plan and manage a personal workload effectively, working independently to meet agreed objectives and deadlines.
- Contribute to the achievement of monthly coding targets and support team performance during periods of absence or increased workload.
- Use patient administration, pathology, radiology and other clinical systems to gather and validate information required for coding.
- Ensure coded data, patient demographics and admission, transfer and discharge details are recorded accurately and promptly.
- Identify and report data quality issues to ensure patient activity is accurately captured within Trust systems.
- Maintain professional competence through continuous learning, participation in coding reviews and completion of mandatory national refresher training.
- Contribute to the continuous improvement of coding quality, data accuracy and compliance with national standards.
Qualifications Essential
- NCCQ Accreditation (ACC)
- Clinical Coding Standards Refresher training certification within last 3 years
- Degree or equivalent training and experience
Desirable
- Anatomy & Physiology or Human biology qualification
- Attendance at NHS Digital approved clinical coding workshops or specialty courses
Experience Essential
- Significant experience of coding inpatient activity across a wide range of specialties within hospital setting
- Demonstrable knowledge, experience and understanding of ICD10 & OPCS 4 classifications and standards
- Experience of using both paper and electronic records to extract clinical information for the purposes of clinical coding