Clinical Coder - GP surgery

NHS; Ware; On-site; GBP 25,000 - 35,000; Full time

Job summary

A healthcare organization in Ware is seeking a Clinical Coder to maintain patient records with precision. The role involves coding clinical data, ensuring compliance with NHS standards, and requires strong analytical skills and attention to detail. The ideal candidate will have qualifications in medical terminology and relevant experience within NHS primary care settings. This position supports efficient communication with healthcare professionals.

Qualifications

• Experience working in NHS primary care.
• Ability to work accurately under pressure.
• Strong attention to detail and analytical skills.

Responsibilities

• Accurately clinically coding data into patient records.
• Organise and update medical records.
• Ensure timely submission of clinical coding data.

Skills

Attention to detail

Organisational skills

Excellent communication

Education

Minimum GCSE Grade A to C in English and Maths

Certification in medical terminology

National Clinical Coding qualification

Tools

SystmOne

Job description

New River Health is a busy GPPractice with 17,500 registered patients across two sites in Hertford and Ware.

We require a Clinical Coder with a commitment to highquality patient care to support with workflow and coding of relevant information into patients' electronic healthcare records on the clinical system, in an accurate, timely, safe and efficient manner.

Main duties of the job

Clinical Coding & Data Entry

Accurately clinically coding data on the clinical systeminto the patient record

Identifying relevant clinicalinformation documented in patient correspondence, coding appropriately andcompleting any detailed action

Ensure that all incoming medical records andcorrespondence are reviewed, summarised, and coded into the clinicalsystem (SystmOne)

File electronic documents and enter key datafollowing the established Coding Protocol and Quality and OutcomesFramework (QOF) guidelines.

Organise and update medical records, linkingproblem titles appropriately.

Workflow & Communication

Highlight and direct critical clinical informationto GPs and healthcare professionals as per the Workflow Protocol.

Ensure timely and accurate submission of clinicalcoding data to meet NHS and National Submission deadlines.

Work collaboratively with clinicians,administrative staff, and external healthcare organisations to improvecoding accuracy.

Identify knowledge gaps and seek advice fromclinical or administrative colleagues when necessary.

Compliance & QualityAssurance

Ensure coding accuracy meets national clinicalcoding standards and NHS regulations.

Maintain confidentiality and comply with DataProtection (GDPR) and NHS Information Governance standards.

Support the team in identifying and resolvingcoding discrepancies.

About us

New River Health is a busyteaching and training practice that provide medical services across two sitesin Hertford and Ware. It is a busy but supportive environment, and we value ourcolleagues in all teams.

Job responsibilities

Job Summary:

The Clinical Coder plays a crucial role in ensuring the accurate entry and maintenance of patient medical records. The primary responsibility includes reviewing, summarising, and coding patient information from medical correspondence and clinical documentation while adhering to national clinical coding standards and practice protocols.

This position requires a detail-oriented professional with knowledge of medical terminology, strong organisational skills, and the ability to work independently while liaising with healthcare professionals. Must know how to use SystmOne.

Main duties of the job

Key Responsibilities: Clinical Coding & Data Entry

Accurately clinically coding data on the clinical system into the patient record

Identifying relevant clinical information documented in patient correspondence, coding appropriately and completing any detailed action

Inputting and extracting data as required to support practice reports

• Ensure that all incoming medical records and correspondence are reviewed, summarised, and coded into the clinical system (SystmOne)
• File electronic documents and enter key data following the established Coding Protocol and Quality and Outcomes Framework (QOF) guidelines.
• Organise and update medical records, linking problem titles appropriately.

Workflow & Communication

• Highlight and direct critical clinical information to GPs and healthcare professionals as per the Workflow Protocol.
• Ensure timely and accurate submission of clinical coding data to meet NHS and National Submission deadlines.
• Work collaboratively with clinicians, administrative staff, and external healthcare organisations to improve coding accuracy.
• Identify knowledge gaps and seek advice from clinical or administrative colleagues when necessary.

Compliance & Quality Assurance

• Ensure coding accuracy meets national clinical coding standards and NHS regulations.
• Maintain confidentiality and comply with Data Protection (GDPR) and NHS Information Governance standards.
• Participate in internal audits and training sessions to enhance coding quality.
• Support the team in identifying and resolving coding discrepancies.
• High accuracy and attention to detail in coding and data entry.
• Ability to work independently.
• Strong organisational and time management skills to handle a large volume of medical records.
• Excellent communication skills (verbal and written) to interact with clinicians and administrative staff.
• Understanding of confidentiality and information governance in a healthcare environment.

Person Specification

Qualifications

• Minimum GCSE Grade A to C in English and Maths or equivalent
• Certification in medical terminology
• National Clinical Coding qualification
• The role could suit someone working towards a clinical qualification

Experience

• Experience working in NHS primary care (GP surgery, PCN)
• Proficiency in using clinical systems- SystmOne
• Ability to work accurately under pressure and meet strict deadlines
• Strong attention to detail and analytical skills.
• Familiarity with QOF and NHS reporting standards.
• Experience working in a GP practice or NHS environment.
• Ability to follow policy and procedure
• Ability to work as a team member and autonomously
• Experience of administrative duties
• Experience working in a GP practice or in a healthcare setting

Skills and Competencies

• High accuracy and attention to detail in coding and data entry.
• Ability to work independently and as part of a team in a remote or in-person setting.
• Strong organisational and time management skills to handle a large volume of medical records.
• Excellent communication skills (verbal and written) to interact with clinicians and administrative staff.
• Understanding of confidentiality and information governance in a healthcare environment.

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.