Trainee clinical coder

Band 3 · Clinical coder · 233 job evaluation points

A trainee clinical coder learns to code straightforward hospital episodes under close supervision, working towards a clinical coding qualification.

Responsibilities

Code straightforward episodes, such as day cases, from health records using classification rules, with all work checked by a senior coder.
Learn medical terms, anatomy, and the national and international coding standards through structured training.
Find, track, and return health records correctly, and keep them secure.
Record coded data in the patient administration or coding system accurately and on time.
Raise unclear or missing information with a senior coder.

Skills

Skill	Expected level	What this level means
Clinical codingThis reference	Awareness (1)	You can: explain what clinical coding is and why it matters use basic medical terms and anatomy
Clinical terminology and classificationThis reference	Awareness (1)	You can: explain the difference between a clinical terminology and a classification recognise common terminologies such as SNOMED CT and ICD
Health records managementThis reference	Awareness (1)	You can: file, find, and track records correctly protect records from loss or unauthorised access
Data quality managementThis reference	Awareness (1)	You can: explain why accurate health data matters for care and planning record data accurately and report errors
Information governance and data protectionThis reference	Awareness (1)	You can: follow the organisation's rules for handling personal and health information recognise and report a data breach or near miss
Understanding health and care servicesThis reference	Awareness (1)	You can: describe the main parts of the health and care system and the services the organisation supports explain why patient safety and confidentiality matter in your work

Typical qualifications and experience

Good literacy and keyboard skills, and enrolment on a clinical coding training programme, or equivalent.

Band 3 outline

Knowledge: Knowledge of a range of procedures, some non-routine; typically a level 3 qualification or equivalent experience.
Autonomy: Works within procedures; decides how to organise own work; refers problems upward.
Scope: Own work and some tasks for the wider team.
Leadership: May allocate routine work or train others in procedures.
Accountability: Accuracy of own work and of records kept.

Job evaluation (illustrative)

Factor	Level	Level summary	Points
Communication and relationship skills	3	Gives routine information needing tact or persuasion, or complex or sensitive information, or straightforward training to groups.	21
Knowledge, training, and experience	3	A range of procedures, some non-routine, needing base-level theory (for example a level 3 qualification or equivalent experience).	60
Analytical and judgemental skills	2	Judgements on facts or situations, some needing analysis.	15
Planning and organisational skills	2	Plans straightforward tasks or activities, some ongoing.	15
Physical skills	3	Developed skills needing speed or accuracy, such as advanced keyboard use.	27
Responsibility for patient and client care	1	Helps patients, clients, or relatives during incidental contact.	4
Responsibility for policy and service development	1	Follows policies set by others; may comment on changes.	5
Responsibility for financial and physical resources	1	Takes personal care of equipment and resources used in own work.	5
Responsibility for people	1	Shows own work routines to new or less experienced colleagues.	5
Responsibility for information resources	3	Takes formal minutes, regularly writes reports or queries, or maintains information systems as a significant duty.	16
Responsibility for research and development	1	Carries out surveys or audits for own work; occasionally takes part in research or testing.	5
Freedom to act	2	Follows standard procedures and precedent; someone is usually available to ask; work may be checked.	12
Physical effort	2	Frequent sitting or standing in a restricted position, or occasional light to moderate effort.	7
Mental effort	4	Frequent prolonged concentration, or occasional intense concentration.	18
Emotional effort	2	Occasional exposure, or frequent indirect exposure, to distressing circumstances.	11
Working conditions	2	Occasional unpleasant conditions, frequent travel or outdoor work, or near-continuous screen use on most days.	7
Total (Band 3: 216 to 270)			233

Mental effort is level 4 because coders concentrate for long periods reading and interpreting detailed case notes. Emotional effort is level 2 because coders frequently read records describing distressing events.