Job summary A Clinical Coder is responsible for the extraction and analysis of complex clinical information from clinical documents/systems relating to a patient's episode in hospital. The Clinical Coder translates the medical terminology applying relevant national clinical coding standards into codes from Classifications used nationally and internationally and record these as a key component of the patient's clinical history. They will use judgement to translate complex cases where a procedure or diagnosis may not be readily codeable. The post-holder will participate fully in the Standards Training Course for Clinical Coding as well as other internal clinical coding courses that make up a comprehensive Training programme. After successful qualification the post holder will be supported in working towards the Accredited Clinical Coding qualification (ACC). Main duties of the job Retrieve and interpret clinical information from electronic patient record and other clinical source documents/systems, check data quality and record necessary amendments Term and encode clinical information in accordance with national guidance for clinical coding and classification systems and with local policies and procedures Abstract and analyse clinical terms from EPR and other relevant clinical source systems using judgement to obtain the correct diagnosis and procedure codes where details may be complex or conflicting. Apply clinical coding rules and conventions, seeking help from the Senior Clinical Coder as required. Ensure that coded clinical information is timely, complete, and accurate to support National Payment Tariff System. Keep abreast of any proposed changes to the clinical coding process and changes within the customer organisations which may impact on the clinical coding process About us We employ more than 6,500 staffwho deliver compassionate care from our two main hospitals,Calderdale Royal Hospital and Huddersfield Royal Infirmary as well as in community sites, healthcentres and in patients' homes. We also are incredibly proud to have almost 150 volunteers here at CHFT. We provide a range of services including urgent and emergency care; medical; surgical; maternity; gynaecology; critical care; children's and young people's services; end of life care and outpatient and diagnostic imaging services. We provide community health services, including sexual health services in Calderdale from Calderdale Royal and local health centres. These include Todmorden Health Centre and Broad Street Plaza. We continue to modernise and invest in our health services to build on our strong reputation.Foundation trusts are public leaders in improving quality in health services. They are part of the NHS- yet decisions about what they do and how they do it are driven by independent boards. Boardslisten to their Council of Governors and respond to the needs of their members - patients, staff andthe local community. Foundation trusts provide what the health service wants, yet are also free to invest quickly in thechanges to the local community needs, in striving to be the best, and in putting their patients first. Date posted 21 March 2025 Pay scheme Agenda for change Band Band 3 Salary £24,071 to £25,674 a year per annum, pro rata Contract Permanent Working pattern Full-time, Flexible working Reference number 372-THIS1354 Job locations The Health Informatics Service Unit 13, Ainlleys Industrial Estate Elland HX5 9JP Job description Job responsibilities Retrieve and interpret clinical information from electronic patient record and other clinical source documents/systems, check data quality and record necessary amendments Term and encode clinical information in accordance with national guidance for clinical coding and classification systems and with local policies and procedures Abstract and analyse clinical terms from EPR and other relevant clinical source systems using judgement to obtain the correct diagnosis and procedure codes where details may be complex or conflicting. Apply clinical coding rules and conventions, seeking help from the Senior Clinical Coder as required. Ability to identify and highlight any Clinical Coding issues and look to resolve such issues by liaising with the Senior Clinical Coder Liaise with clinical staff to ensure correct interpretation of clinical information Ensure that coded clinical information is timely, complete, and accurate to support National Payment Tariff System. Keep abreast of any proposed changes to the clinical coding process and changes within the customer organisations which may impact on the clinical coding process Work on your own initiative, prioritising workload as required. Be prepared to self-study and research on the internet. Carry out any other duties and responsibilities commensurate with the grade. Be aware of our customer requirements Be aware of developments within THIS Participate in delivery of work programmes Manage own work to deliver agreed programmes on time and in full Responsible for your own monthly time sheets and completing AMS (Activity Management System) ROD (Remedy on Demand) on a regular weekly basis Observe personal duty of care when using office equipment and machinery Attend all mandatory training Participate annually identifying, developing, and agreeing your own development plan with your Line Manager using the Trust Appraisal Comply with all Trust policies, procedures, and protocols. Carry out duties with due regard to the Trusts Equal Opportunity Policy. Seek advice and support from Line Manager whenever necessary. Maintain professional conduct including appearance at all times Job description Job responsibilities Retrieve and interpret clinical information from electronic patient record and other clinical source documents/systems, check data quality and record necessary amendments Term and encode clinical information in accordance with national guidance for clinical coding and classification systems and with local policies and procedures Abstract and analyse clinical terms from EPR and other relevant clinical source systems using judgement to obtain the correct diagnosis and procedure codes where details may be complex or conflicting. Apply clinical coding rules and conventions, seeking help from the Senior Clinical Coder as required. Ability to identify and highlight any Clinical Coding issues and look to resolve such issues by liaising with the Senior Clinical Coder Liaise with clinical staff to ensure correct interpretation of clinical information Ensure that coded clinical information is timely, complete, and accurate to support National Payment Tariff System. Keep abreast of any proposed changes to the clinical coding process and changes within the customer organisations which may impact on the clinical coding process Work on your own initiative, prioritising workload as required. Be prepared to self-study and research on the internet. Carry out any other duties and responsibilities commensurate with the grade. Be aware of our customer requirements Be aware of developments within THIS Participate in delivery of work programmes Manage own work to deliver agreed programmes on time and in full Responsible for your own monthly time sheets and completing AMS (Activity Management System) ROD (Remedy on Demand) on a regular weekly basis Observe personal duty of care when using office equipment and machinery Attend all mandatory training Participate annually identifying, developing, and agreeing your own development plan with your Line Manager using the Trust Appraisal Comply with all Trust policies, procedures, and protocols. Carry out duties with due regard to the Trusts Equal Opportunity Policy. Seek advice and support from Line Manager whenever necessary. Maintain professional conduct including appearance at all times Person Specification QUALIFICATIONS / TRAINING Essential GCSE grades 9-4 (A-C) or equivalent in English, Maths and Science Desirable AMSPA in Medical Terminology European Computer Driving Licence or equivalent Clinical Coding Standards Course KNOWLEDGE, EXPERIENCE & EXPERTISE Essential Working as part of a team and supporting others Desirable Experience of working in a Patient Services environment Experience of Medical Terminology Microsoft Office NHS experience A good understanding of patient confidentiality and the Data Protection Act Experience of Clinical Coding/Working Towards Clinical Coding Standards Course Experience of NHS Clinical Systems Knowledge of undergraduate and postgraduate medicine COMMUNICATION AND RELATIONSHIPS (INCLUDING MANAGEMENT RESPONSIBILITIES) Essential Demonstrates enthusiasm for self-development The ability to communicate at all levels with tact and diplomacy The ability to prioritise activities according to deadlines The ability to work under pressure The ability to work as part of a team and on own The ability to use own Initiative The ability to be thorough, accurate and reliable Maintenance of confidentiality Desirable The ability to interpret Clinical Information Experience of working with different software systems in the NHS environment Driving Licence and car owner Person Specification QUALIFICATIONS / TRAINING Essential GCSE grades 9-4 (A-C) or equivalent in English, Maths and Science Desirable AMSPA in Medical Terminology European Computer Driving Licence or equivalent Clinical Coding Standards Course KNOWLEDGE, EXPERIENCE & EXPERTISE Essential Working as part of a team and supporting others Desirable Experience of working in a Patient Services environment Experience of Medical Terminology Microsoft Office NHS experience A good understanding of patient confidentiality and the Data Protection Act Experience of Clinical Coding/Working Towards Clinical Coding Standards Course Experience of NHS Clinical Systems Knowledge of undergraduate and postgraduate medicine COMMUNICATION AND RELATIONSHIPS (INCLUDING MANAGEMENT RESPONSIBILITIES) Essential Demonstrates enthusiasm for self-development The ability to communicate at all levels with tact and diplomacy The ability to prioritise activities according to deadlines The ability to work under pressure The ability to work as part of a team and on own The ability to use own Initiative The ability to be thorough, accurate and reliable Maintenance of confidentiality Desirable The ability to interpret Clinical Information Experience of working with different software systems in the NHS environment Driving Licence and car owner Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions. Employer details Employer name Calderdale and Huddersfield NHS Foundation Trust Address The Health Informatics Service Unit 13, Ainlleys Industrial Estate Elland HX5 9JP Employer's website https://www.cht.nhs.uk (Opens in a new tab)