Clinical Coder and Administrative SupportNHS

Job summary

Millrise Medical Practice is looking for an organised, accurate and motivated individual to join our practice team.

The primary focus of this role is clinical coding and maintaining accurate patient records. The post holder will review and summarise information from patient clinical records and incoming clinical correspondence, accurately apply appropriate clinical codes, and ensure relevant information is recorded and highlighted for the clinical team.

The role will also provide medical secretarial and administrative support to the practice when required, including processing referrals, managing correspondence, supporting electronic referral systems and liaising with hospitals, secondary care, community services and other external organisations.

We are looking for someone with excellent attention to detail, strong organisational and time-management skills, and the ability to work independently while contributing positively to a busy multidisciplinary team. Experience of clinical coding, medical terminology, GP practice systems or medical administration would be advantageous.

This is an excellent opportunity for someone looking to develop their experience within primary care clinical coding, alongside supporting the practice with medical secretarial and administrative duties.

Main duties of the job

• To undertake clinical coding and associated patient record management to support the delivery of high-quality patient care.
• To provide medical secretarial and administrative support to the clinical team.
• To ensure work is completed accurately, efficiently and within required timescales.
• To work collaboratively with colleagues across the Practice and contribute to a positive team environment.
• To maintain confidentiality and comply with Practice policies, procedures and information governance requirements.
• To manage and prioritise workload effectively, using initiative and demonstrating a flexible approach.
• To contribute to the ongoing development and improvement of Practice processes and services.
• To undertake training and professional development relevant to the role.

Job description

Job Summary

The post holder will be an integral member of the Practice Team, providing a combination of clinical coding, medical secretarial and administrative support to ensure that patient information is accurately recorded, processed and communicated in a timely and effective manner.

The post holder will be responsible for summarising and accurately coding relevant information from patient clinical records, processing incoming clinical correspondence, maintaining accurate patient records and ensuring that relevant clinical information is appropriately highlighted for healthcare professionals.

The role will also provide comprehensive secretarial and administrative support to the multidisciplinary team, including the processing and management of referrals, correspondence, electronic referral systems, requests for information and communication with secondary care, community services and other external agencies.

The post holder will work collaboratively with clinical and administrative colleagues, supporting the effective delivery of patient services and providing appropriate administrative and reception cover when required.

Key Responsibilities

Clinical Coding and Patient Records

• Summarise and code patient records into the Practice computer system to a high standard.
• Read and process incoming correspondence, accurately coding relevant diagnoses, procedures and other clinical information within patient records.
• Review clinical correspondence and determine whether information or follow-up actions need to be brought to the attention of a GP or other appropriate member of the clinical team.
• Analyse patient records and extract and accurately record relevant clinical information to produce an accurate summary of the patient's medical history.
• Scan patient-related documents and attach them to the appropriate patient healthcare record, using codes as agreed by the clinical team.
• Ensure incoming clinical correspondence is processed and scanned within the Practice's required timescales.
• Assign appropriate, industry-recognised clinical codes.
• Ensure all relevant QOF-related data is accurately captured.
• Maintain and develop knowledge of anatomy, physiology and medical terminology relevant to the role.

Administrative Support

Undertake the following administrative responsibilities as required to provide service cover during periods of staff illness, annual leave or increased workload as required.

• Type letters, reports and associated documentation as required.
• Process referrals efficiently and accurately, including referrals through the Electronic Referral Service.
• Liaise with hospitals, secondary care, community services and other external agencies regarding patient referrals and associated queries.
• Process incoming correspondence and emails in a timely manner.
• Process requests for information, including Subject Access Requests (SARs), insurance and solicitor's letters and DVLA forms, in accordance with Practice procedures.
• Support clinical staff with general administrative and secretarial duties as required.
• Produce meeting agendas and accurately record meeting minutes where required.

Team Working and Service Support

• Work effectively as part of a multidisciplinary team.
• Support colleagues and contribute positively to the wider Practice team.
• Prioritise workload and use effective time-management strategies.
• Provide administrative and reception support during periods of staff absence or increased workload.
• Undertake other reasonable duties as required to maintain effective service delivery.

Confidentiality and Information Governance

• The post holder will have access to confidential and sensitive information relating to patients, carers and Practice staff and must maintain strict confidentiality at all times.
• Respect patients' rights to privacy and confidentiality.
• Adhere to all Practice policies and procedures relating to the protection of personal and sensitive information.
• Ensure confidential information is only disclosed to authorised persons and in accordance with Practice procedures and relevant legislation.
• Ensure patient records and correspondence are handled securely and appropriately.

Health, Safety and Risk Management

The post holder will assist in promoting and maintaining their own and others' health, safety and security in accordance with Practice policies and procedures.

This will include:

• Identifying risks associated with work activities and undertaking work in a manner that manages those risks.
• Reporting potential risks, incidents or concerns to the appropriate manager or Practice Partner.
• Taking appropriate action to minimise risks within the scope of the role.

Equality and Diversity

The post holder will support the equality, diversity and rights of patients, carers and colleagues by:

• Acting in accordance with Practice procedures, policies and current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
• Maintaining a welcoming, non-judgemental and respectful approach.
• Recognising and responding appropriately to individual circumstances, needs, feelings and priorities.
• Ensuring statutory requirements relating to equality and diversity are met.

Quality and Continuous Improvement

The post holder will contribute to maintaining and improving quality within the Practice by:

• Alerting colleagues and managers to issues relating to quality, accuracy or risk.
• Taking responsibility for the accuracy and quality of their own work.
• Managing time, workload and resources effectively.
• Contributing to audits and quality improvement activities as required.
• Reflecting on individual and team processes and suggesting ways in which performance and patient services could be improved.
• Supporting the Practice in maintaining accurate clinical records and achieving relevant quality requirements, including QOF-related data capture.

Personal Development

The post holder will:

• Participate in training programmes implemented by the Practice.
• Participate in an annual individual performance review.
• Take responsibility for their own learning, development and performance.
• Maintain knowledge and skills appropriate to clinical coding, medical terminology, referrals, Practice systems and administrative processes.
• Share knowledge and skills with colleagues where appropriate.
• Undertake additional training where required to support the needs of the role.

Skills and Experience

The post holder should demonstrate:

• Ability to work effectively as part of a multidisciplinary team.
• Excellent organisational and time-management skills.
• Ability to work independently and use initiative.
• Ability to prioritise workload effectively and work to tight deadlines.
• Excellent attention to detail and accuracy.
• Effective written and verbal communication skills.
• Ability to communicate professionally with patients, colleagues and external healthcare organisations.
• Good knowledge and understanding of Microsoft Office, including Word and Excel.
• Ability to work effectively under pressure while maintaining accuracy.
• Good understanding of confidentiality and the importance of protecting patient information.
• Willingness to develop and maintain knowledge of clinical terminology, coding and Practice administrative procedures.

Other Duties

The post holder may, from time to time, be asked to undertake other reasonable duties appropriate to the role and their level of competence, with appropriate training provided where required.

As a member of the Practice Team, the post holder is expected to be flexible and willing to undertake additional or relinquish existing duties where necessary to maintain effective service delivery to patients. Requests from the Practice Partners and management team should not be unreasonably refused.

About us

We are an innovative, team-orientated and well-organised teaching Practice who pride ourselves in ensuring that patients are equal partners in their care.

• 3 GP Partners, 1 Salaried GP, 1 Clinical Pharmacist, 3 Nurse Practitioners, 1 Practice Nurse, 1 Nursing Associate, 1 GP Assistant
• Full administrative support from a Practice Manager, Data & Quality Lead, Clinical Governance Support Officer plus other Administrators
• Long standing training practice with an excellent reputation & support for continuing medical education and CPD time
• CQC rating of Good
• Research practice with good links to Keele University
• High achiever in QoF/QIF