Job summary The role of the Clinical Coder is to extract and translate written medical terminology from patient case notes into coded data, for use in Payment by Results and statistical analysis. This involves the study of all written information and electronic reports and letters to establish all the diagnosed conditions, treatments and procedures undertaken within the relevant episode of care and recording this information using national classifications onto the Patient Administration System (PAS). The ability to concentrate for long periods of time is essential within the Coding Department in order to deal with complex information. Applicants from job seekers who require current Skilled Worker Sponsorship to work in the UK are welcome and will be considered alongside all other applications.Job seekers should be aware that not all roles will be eligible for Skilled Worker Sponsorship. For further information visit UK Visas and Immigration - GOV.UK (www.gov.uk) Main duties of the job Extract relevant information from case notes to enable coding of clinical activity Adhere to national and international rules and standards including ICD10 and OPCS version 4 Responsible for accurate completion of inpatient and day case episodes - referring complex cases to the Clinical Coding Manager Take responsibility for entry of clinical codes onto the patient administration/electronic patient record system Develop and maintain good links with clinical staff to ensure quality of data Assist with clinical coding audits Work towards accredited clinical coding ACC qualification About us The Robert Jones and Agnes Hunt Orthopaedic NHS Trust (RJAH) is one of the leading orthopaedic hospitals in the country, with some of the highest levels of staff and patient satisfaction, as well as a strong reputation for research and innovation. Joining RJAH is more than just a job - we want our people to have the best opportunities to thrive in their role.We have a range of fantastic staff benefits on offer to everyone who joins RJAH and you'll have access to outstanding professional development opportunities and state-of-the-art facilities - including our recently-opened £6 million Headley Court Veterans' Orthopaedic Centre (the first unit of its kind in the UK).RJAH has strong links with a range of universities including Staffordshire, Keele, Glyndwr, Chester and Birmingham.The hospital is located on a site outside Oswestry in Oswestry, just off the A5. The nearest train station is in Gobowen, approximately two miles from the hospital. The station is part of the Chester to Birmingham line.We are based in North Shropshire, close to the border with North and Mid Wales. It is one of the most attractive parts of the country, with a rich historic culture and excellent transport links. It offers outstanding opportunities for anyone who enjoys an outdoor lifestyle or is looking to raise a family. Date posted 22 January 2025 Pay scheme Agenda for change Band Band 3 Salary £24,071 to £25,674 a year pa (Subject to Banding) Contract Permanent Working pattern Full-time, Flexible working, Home or remote working Reference number 224-PA20241102197 Job locations RJAH Orthopaedic Hospital FT Oswestry SY10 7AG Job description Job responsibilities Key working Relationships Finance Department, Information Department, IT Department, Clinicians, other Medical and Nursing staff, Ward staff and Healthcare Records staff. Main Responsibilties To extract relevant information from case notes/source documents to enable the coding of clinical activity. To critically analyse the data from all available sources relevant to the episode of care and interpret this information using the current classifications (World Health Organisation ICD10 and Office of Population Censuses and Surveys version 4), applying national and international rules and conventions whilst maintaining accuracy and completeness of coding. This will require the use of initiative and judgment to reconcile the given diagnoses and to integrate new procedures. To be responsible for accurate completion of all in patient and day case episodes ensuring that all relevant information is coded, referring where necessary in complex cases to the Clinical Coding Manager. To be responsible for meeting existing targets of completed coding and to ensure that the agenda for Payment by Results (PbR) is achieved through accurate and timely coding. To take responsibility for entering the coded clinical information onto the Patient Administration System (PAS). To identify missing activity for all specialities by producing daily/weekly lists of uncoded activity, using the information available from electronic patient records, discharge summaries, x-ray reports and histology reports. To report any discrepancies in data provision to the relevant Ward/Department and the Clinical Coding Manager. To check and amend coded data regarding patient episodes on the Patient Administration System ensuring that all the information is accurate and complete. To develop and maintain good links with clinical staff to improve and ensure good quality and depth of clinical coded data, amending clinical coding where necessary. To ensure that medical case notes are kept in good order and booked out to the correct Department after the coding episode has been completed. To assist with the preparation of Information Governance and PbR Audits by pulling and returning medical case notes to and from the Records Library. To attend the mandatory external NHS 18 day Clinical Coding Foundation Course. To work towards the national accredited clinical coding ACC qualification or the Trust internal assessment. To take responsibility for maintenance and improvements of clinical coding knowledge by attendance at the mandatory external NHS two yearly Refresher Training Course and other speciality courses in line with Department training plans. To be responsible for identifying personal training and development needs through appraisals in line with Trust policies. To provide codes to the Information Department to enable data analysis for statistical and research purposes. To provide coding information to other Departments within the Trust as and when required. To provide support and cover as required within the Department. To attend meetings as requested and within own remit. To promote the professional image of the Clinical Coding Department throughout the Trust and to ensure that all duties are carried out in a professional manner. To main confidentiality at all times in line with the Data Protection Act. Job description Job responsibilities Key working Relationships Finance Department, Information Department, IT Department, Clinicians, other Medical and Nursing staff, Ward staff and Healthcare Records staff. Main Responsibilties To extract relevant information from case notes/source documents to enable the coding of clinical activity. To critically analyse the data from all available sources relevant to the episode of care and interpret this information using the current classifications (World Health Organisation ICD10 and Office of Population Censuses and Surveys version 4), applying national and international rules and conventions whilst maintaining accuracy and completeness of coding. This will require the use of initiative and judgment to reconcile the given diagnoses and to integrate new procedures. To be responsible for accurate completion of all in patient and day case episodes ensuring that all relevant information is coded, referring where necessary in complex cases to the Clinical Coding Manager. To be responsible for meeting existing targets of completed coding and to ensure that the agenda for Payment by Results (PbR) is achieved through accurate and timely coding. To take responsibility for entering the coded clinical information onto the Patient Administration System (PAS). To identify missing activity for all specialities by producing daily/weekly lists of uncoded activity, using the information available from electronic patient records, discharge summaries, x-ray reports and histology reports. To report any discrepancies in data provision to the relevant Ward/Department and the Clinical Coding Manager. To check and amend coded data regarding patient episodes on the Patient Administration System ensuring that all the information is accurate and complete. To develop and maintain good links with clinical staff to improve and ensure good quality and depth of clinical coded data, amending clinical coding where necessary. To ensure that medical case notes are kept in good order and booked out to the correct Department after the coding episode has been completed. To assist with the preparation of Information Governance and PbR Audits by pulling and returning medical case notes to and from the Records Library. To attend the mandatory external NHS 18 day Clinical Coding Foundation Course. To work towards the national accredited clinical coding ACC qualification or the Trust internal assessment. To take responsibility for maintenance and improvements of clinical coding knowledge by attendance at the mandatory external NHS two yearly Refresher Training Course and other speciality courses in line with Department training plans. To be responsible for identifying personal training and development needs through appraisals in line with Trust policies. To provide codes to the Information Department to enable data analysis for statistical and research purposes. To provide coding information to other Departments within the Trust as and when required. To provide support and cover as required within the Department. To attend meetings as requested and within own remit. To promote the professional image of the Clinical Coding Department throughout the Trust and to ensure that all duties are carried out in a professional manner. To main confidentiality at all times in line with the Data Protection Act. Person Specification Qualifications Desirable 5 GCSE's including Maths and English (or equivalent) ECDL/ICDL or equivalent Medical Secretary Training Experience Desirable NHS/Medical Office Environment Experience Experience in Computer systems Skills and Knowledge Essential Attention to detail Able to work on own initiative Basic knowledge of anatomy and physiology Knowledge of medical terminology Aptitude and Attributes Essential Good communication / interpersonal skills Ability to work under a high degree of accuracy under pressure Good telephone manner Discretion when dealing with sensitive and confidential information Able to prioritise and organise workload Able to learn and remember complex information Excellent concentration skills Desirable Team player Able to work flexibly Person Specification Qualifications Desirable 5 GCSE's including Maths and English (or equivalent) ECDL/ICDL or equivalent Medical Secretary Training Experience Desirable NHS/Medical Office Environment Experience Experience in Computer systems Skills and Knowledge Essential Attention to detail Able to work on own initiative Basic knowledge of anatomy and physiology Knowledge of medical terminology Aptitude and Attributes Essential Good communication / interpersonal skills Ability to work under a high degree of accuracy under pressure Good telephone manner Discretion when dealing with sensitive and confidential information Able to prioritise and organise workload Able to learn and remember complex information Excellent concentration skills Desirable Team player Able to work flexibly 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. Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab). From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab). Additional information 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. Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab). From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab). Employer details Employer name Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Address RJAH Orthopaedic Hospital FT Oswestry SY10 7AG Employer's website https://www.rjah.nhs.uk/ (Opens in a new tab)