Clinical Coder

Job Description Clinical CoderJob PurposeThe Clinical Coder is responsible for the accurate translation of clinical diagnoses, procedures and interventions into nationally recognised clinical codes using ICD-10 and OPCS-4 classifications. The role is fundamental in supporting patient care, clinical governance, performance reporting, service planning and regulatory compliance across Optimised Care. Working closely with consultants, clinicians and multidisciplinary teams, the Clinical Coder will ensure that all coded information is complete, accurate and compliant with national coding standards and organisational policies. Key Responsibilities • Review inpatient, day case and outpatient medical records to extract relevant clinical information. • Assign accurate ICD-10 diagnostic codes and OPCS-4 procedure codes in accordance with the latest NHS Clinical Coding Standards. • Ensure all clinical coding is completed within agreed timescales to support reporting, governance and operational performance. • Analyse complex clinical documentation, including consultant notes, operation records, pathology reports and diagnostic investigations. • Liaise professionally with consultants and clinical teams to clarify incomplete or ambiguous documentation where necessary. • Maintain high levels of coding accuracy through continuous quality assurance and audit compliance. • Support internal and external clinical coding audits by providing evidence of coding decisions. • Identify documentation issues that may affect coding quality and work collaboratively to improve clinical documentation standards. • Maintain confidentiality and comply with GDPR, Information Governance and organisational policies at all times. • Keep up to date with national coding guidance, ICD-10 and OPCS-4 updates and changes in clinical coding standards. • Participate in mandatory training, departmental meetings and continuing professional development activities. • Contribute to service improvement initiatives that enhance coding quality, efficiency and patient data integrity. Knowledge, Skills and ExperienceEssential • Accredited Clinical Coding Standards Course (ACCS) qualification or equivalent. • Proven experience working as a Clinical Coder within the NHS or independent healthcare sector. • Comprehensive knowledge of ICD-10 and OPCS-4 classifications. • Understanding of NHS Clinical Coding Standards and Data Quality requirements. • Ability to interpret complex medical terminology and clinical documentation. • Excellent attention to detail with a high level of accuracy. • Strong analytical and organisational skills. • Excellent communication and interpersonal skills. • Competent user of Electronic Patient Record (EPR) systems and Microsoft Office applications. • Ability to prioritise workload and consistently meet deadlines. Desirable • National Clinical Coding Qualification (NCCQ). • Experience within an independent hospital or elective surgical setting. • Knowledge of clinical audit methodologies. • Experience coding across a broad range of medical and surgical specialties. • Understanding of healthcare performance reporting and clinical governance frameworks. Professional Responsibilities • Maintain professional standards and confidentiality at all times. • Demonstrate integrity, accountability and attention to detail in all aspects of the role. • Promote Optimised Care's values through collaboration, respect and professionalism. • Support a culture of continuous improvement and excellence. • Undertake any other reasonable duties appropriate to the role and grade. What We OfferJoining Optimised Care means becoming part of a forward-thinking healthcare organisation committed to excellence. We offer: • Competitive salary. • Generous annual leave entitlement. • Company pension scheme. • Ongoing learning and professional development. • Supportive and collaborative working environment. • Modern clinical systems and technology. • Employee wellbeing initiatives. • Free on-site parking. • Opportunities for career progression within a growing healthcare organisation. • Flexible working hours • Remote work Job description Job responsibilities Job Description Clinical CoderJob PurposeThe Clinical Coder is responsible for the accurate translation of clinical diagnoses, procedures and interventions into nationally recognised clinical codes using ICD-10 and OPCS-4 classifications. The role is fundamental in supporting patient care, clinical governance, performance reporting, service planning and regulatory compliance across Optimised Care. Working closely with consultants, clinicians and multidisciplinary teams, the Clinical Coder will ensure that all coded information is complete, accurate and compliant with national coding standards and organisational policies. Key Responsibilities • Review inpatient, day case and outpatient medical records to extract relevant clinical information. • Assign accurate ICD-10 diagnostic codes and OPCS-4 procedure codes in accordance with the latest NHS Clinical Coding Standards. • Ensure all clinical coding is completed within agreed timescales to support reporting, governance and operational performance. • Analyse complex clinical documentation, including consultant notes, operation records, pathology reports and diagnostic investigations. • Liaise professionally with consultants and clinical teams to clarify incomplete or ambiguous documentation where necessary. • Maintain high levels of coding accuracy through continuous quality assurance and audit compliance. • Support internal and external clinical coding audits by providing evidence of coding decisions. • Identify documentation issues that may affect coding quality and work collaboratively to improve clinical documentation standards. • Maintain confidentiality and comply with GDPR, Information Governance and organisational policies at all times. • Keep up to date with national coding guidance, ICD-10 and OPCS-4 updates and changes in clinical coding standards. • Participate in mandatory training, departmental meetings and continuing professional development activities. • Contribute to service improvement initiatives that enhance coding quality, efficiency and patient data integrity. Knowledge, Skills and ExperienceEssential • Accredited Clinical Coding Standards Course (ACCS) qualification or equivalent. • Proven experience working as a Clinical Coder within the NHS or independent healthcare sector. • Comprehensive knowledge of ICD-10 and OPCS-4 classifications. • Understanding of NHS Clinical Coding Standards and Data Quality requirements. • Ability to interpret complex medical terminology and clinical documentation. • Excellent attention to detail with a high level of accuracy. • Strong analytical and organisational skills. • Excellent communication and interpersonal skills. • Competent user of Electronic Patient Record (EPR) systems and Microsoft Office applications. • Ability to prioritise workload and consistently meet deadlines. Desirable • National Clinical Coding Qualification (NCCQ). • Experience within an independent hospital or elective surgical setting. • Knowledge of clinical audit methodologies. • Experience coding across a broad range of medical and surgical specialties. • Understanding of healthcare performance reporting and clinical governance frameworks. Professional Responsibilities • Maintain professional standards and confidentiality at all times. • Demonstrate integrity, accountability and attention to detail in all aspects of the role. • Promote Optimised Care's values through collaboration, respect and professionalism. • Support a culture of continuous improvement and excellence. • Undertake any other reasonable duties appropriate to the role and grade. What We OfferJoining Optimised Care means becoming part of a forward-thinking healthcare organisation committed to excellence. We offer: • Competitive salary. • Generous annual leave entitlement. • Company pension scheme. • Ongoing learning and professional development. • Supportive and collaborative working environment. • Modern clinical systems and technology. • Employee wellbeing initiatives. • Free on-site parking. • Opportunities for career progression within a growing healthcare organisation. • Flexible working hours • Remote work