Clinical Coder

Cardiff and Vale University Health Board; Melton Mowbray; On-site; GBP 26,000 - 36,000; Full time

Job summary

Latham House Medical Practice is seeking an experienced Clinical Coder to screen incoming medical letters, file and summarise patient notes, and direct information to GPs. The role requires proficiency with GP systems (SystmOne, EMIS) and accurate data entry within NHS protocols.

The post emphasises attention to detail, teamwork, and ability to work under supervision, with responsibilities ranging from data capture to clinical action highlighting and administrative support.

Qualifications

• Recent experience in primary care and GP coding.
• Experience handling medical letters and entering data.
• Familiarity with GP clinical information systems and NHS procedures.

Responsibilities

• Screen incoming medical letters and file patient notes.
• Enter data into the electronic medical record with accuracy.
• Highlight clinician actions and route information per Practice Protocol.
• Ensure QOF data is captured and records are up to date.
• Undertake administrative tasks as delegated and support the Practice.

Skills

Attention to detail

Time management

Communication skills

Problem solving

Teamwork

Education

5 GCSEs or equivalent

Tools

SystmOne

EMIS

Docman

Microsoft Office

Job description

It is the responsibility of each Clinical Coder to screen all incoming medical letters, entering key data and selecting and directing appropriate information for GPs attention adhering to the practice policy. The role will involve electronically filing and summarising patients medical notes. The roles and responsibilities may change according to the business requirements., As a member of the Practices Coding Team, the post-holder will screen all incoming medical letters and electronically file and summarise patients medical notes, highlighting clinician action where relevant.,

• Reviewing all incoming correspondence, sorting clinical letters, filing documents and entering pertinent information into the patients electronic medical record in accordance with the Practice Protocol
• Ensuring all QOF related data is captured
• Highlighting clinician action and workflow to appropriate clinician or team as per Practice Protocol
• To correct errors in filing and ensure corresponding records are amended accurately
• Ensuring medical records are kept organised and up to date
• Summarising new patient records to a high standard and according to set protocols and timescales agreed by the Practice.
• Recognising own knowledge limits and seek advice from clinical or administrative colleagues as appropriate.
• To carry out administrative related tasks as delegated by the Clinical Lead and Operations Manager
• To undertake any other reasonable tasks as allocated by the line manager and/or Partners. This job description reflects the immediate requirements and objectives of the post and is not exhaustive

Policy & Procedures

• The post-holder will acquire and maintain an acceptable level of knowledge and understanding of the Practices protocols, policies and procedures
• Having acquired the required level of knowledge and understanding of the Practices protocols, policies and procedures; the post-holder is required to support, promote and adhere to all of the Practices policies

Confidentiality

• In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded and managed as strictly confidential. Additionally, the post-holder will be respectful and courteous to colleagues and patients, for example knocking on doors prior to entry.

Health & Safety

• In addition to being a Fire Marshal/Fire Warden, the post-holder will promote and maintain the health, safety and security of self and others by:
• Using personal security systems within the workplace according to practice guidelines
• Identifying and report risks and potential risks involved in work activities and manage such risks in accordance with agreed procedures
• Maintaining a level of knowledge, understanding and skills to meet the Practices expectations
• Adhering to the Practices fire safety and infection control policies and procedures
• Maintaining work areas, so that work areas are tidy, safe and free from hazards and infection

Equality & Diversity

• The post-holder will support the equality, diversity and rights of patients, carers and colleagues, by:
• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues
• Behaving in a manner which is welcoming, is non-judgmental and respects the circumstances, feelings priorities and rights of others

Quality

• The post-holder is required to adhere to agreed, required and registered standards of quality within the Practice, and will:
• Alert other team members to issues of quality and risk
• Assess their own performance and take accountability for their own actions, either directly or under supervision
• Contribute to the effectiveness of the Practice by reflecting on their own and their teams activities/performance and making suggestions to improve and enhance the teams and Practices performance
• Work effectively with individuals in other agencies to meet patients needs
• Effectively manage their time, workloads and resources to meet the standards expected by the Line Manager and Practice.

Communication

• The post-holder should recognise the importance of effective communication within the team and will strive to:
• Communicate effectively with patients and carers, team members, clinical and non-clinical staff, partners and representatives of external organisations;
• Recognise and accommodate peoples needs for alternative methods of communication.

Other

• The post-holder will be expected and required to undertake and complete any other duties as deemed relevant to position and the business needs of the Practice. This job description will be subject to periodic review and amendment in consultation with the post holder.
• The post holder must attend and participate in all mandatory practice-led training events, team meetings, and staff briefings as required by the Practice. Attendance forms part of the role and is essential to maintaining knowledge, compliance, and effective teamwork.
  Possess a broad knowledge of anatomy and physiology, and medical terminology.
• A good knowledge of working with GP clinical systems such as EMIS/SystmOne, Docman.
• Good, knowledge of IT programs such as Microsoft Office, Excel, Word, Powerpoint, Outlook and databases.
• Understanding of the NHS/Primary Care Services.
• Knowledge of confidentiality in the workplace/information governance.
• Able to establish, maintain and develop effective communications across the Practice and with external organisations.
• Excellent ICT skills.
• Excellent oral and written communication skills; able to engage effectively with a wide range of audiences.
• Ability to analyse and interpret information.
• Methodically and accurate approach to work with attention to detail.
• Excellent time management skills, capable of prioritising and managing competing demands and workloads.
• Able to work under pressure
• Good problem-solving skills. Commitment to continuing professional development of self and others.
• A flexible and adaptable approach to maintain the consistent delivery of high-quality services
• Satisfactory completion of an enhanced check through the Vetting and Barring Service (this will be taken up if offered the post).
• Legal right to work in the UK
• Hep B/MMR - vaccinated or willing to be vaccinated.
• A commitment to anti-discriminatory practices in employment, training and service delivery.
• An understanding of Health and Safety responsibilities.
• Flexibility in working hours. Good standard of education with 5 GCSEs or equivalent or experience in a similar post. Experience of working with GP clinical information and systems such as EMIS, SystmOne, or hospital coding environment.
• Recent and relevant experience of primary care. Evidence of capacity to work in an office autonomously and as part of a team.

Latham House Medical Practice, one of the UKs largest doctors surgeries, are looking for an experienced Clinical Coder for a 6 month fixed term contract. Experience of using SystmOne is essential. We are conveniently situated within 30 to 50 minutes of Nottingham, Leicester and Peterborough; Melton Mowbray is a large market town in the fortunate position of being surrounded by picturesque villages, beautiful countryside, and local activities.