Medical Coder

2 weeks ago

Bedford, Bedford, United Kingdom London Road Health Centre Full time

The Practice operates a paper-light environment, and the main responsibilities of the post-holder will be to summarise and Read Code relevant information from new patient records and the coding of clinical documents onto the practice clinical system (SystmOne).

Will be required to work strictly in accordance with GDPR and with the practice notes summarising protocol.

Main Duties/Key Tasks:

  • Entering the receipt of medical records from PCSE onto the clinical system.
  • Culling and sorting patient records in preparation for summarising.
  • Monitoring progress of notes summarising against practice targets
  • Accurately analyse, code and process patient information to ensure data is comparable over time for local and national use
  • Reviewing medical records and producing an accurate summary of the patient's medical history and read coding this onto the clinical system
  • To maintain and keep up to date data in computerised patient records, including Correction of anomalies in patient records.
  • To maintain the computer clinic system in an accurate and secure manner
  • Review and correct anomalies in patient records
  • To assist with the gathering of statistics and information when required
  • Organise daily workload efficiently so that personal coding targets are met and support the rest of the team in achieving high standards of coding completeness and accuracy within agreed timescales
  • Participate in the audit process, working closely with the Team managers
  • Implement all actions resulting from audit recommendations
  • Assist in the implementation of new initiatives affecting clinical coding and participate in planning of changes of work practice
  • Ensuring computerised records are accurate and up to date
  • Filing and retrieving paper files from the storage room
  • Manage GP to GP electronic record transfers including reviewing degraded entries.
  • To report possible data breaches and serious incidents in a timely manner
  • Overseeing document processing within the organisation, ensuring accurate and safe processing and reporting concerns to the Admin Manager and/or Practice Manager


As this is General Practice the role and post may change as the working environment evolves to keep up to date with future developments within the NHS, it may therefore be necessary to vary the responsibilities and hours as the future needs of the practice dictates, this will only be done after review and consultation.

You will be expected to carry out reasonable duties which may be requested from time-to-time by the practice.

Qualifications & Training
Secondary school qualifications such as GCSE's, O'levels or equivalent including science

Relevant Clinical Coding qualification.

Further education qualifications such as A Levels, Btech, NVQ or equivalent.

Experience
Proven experience of working as a Clinical coder/Medical Records Summariser for 1 year.

Proven experience of working in a healthcare setting for a minimum of 1 year.

Significant experience of working as part of a team for a minimum of 2 years

NHS/private healthcare experience

Experience in GP surgery (primary care)

Knowledge and Skills
Able to work as part of a team, to promote a good team spirit and to be sensitive and assertive as appropriate

Ability to make decisions, use own initiative and be innovative

An understanding, acceptance and adherence to the need for strict patient confidentiality.

Excellent communication skills including ability to listen, to discuss and to inform clearly

Able to demonstrate compassion, empathy and understanding.

Ability to work under pressure

Knowledge of Medical Terminology

Knowledge of SystmOne

Knowledge of Anatomy and Biology, comfortable using a range of medical terminology.

Qualities
Able to remain calm under pressure

Able to work in a constantly changing environment

Able to work on own initiative and without direct supervision at times.

Polite, friendly and articulate manner

Understanding and commitment to equality of opportunity and good working relationships.

Ability to work under pressure in a busy working environment, able to multi-task, focus for long periods.

An understanding, acceptance and adherence to the need for strict confidentiality and data protection.

Ability to use own initiative within clear boundaries, seeking advice when necessary

Ability to organise and prioritise own/team workloads to changing and often tight deadlines

Ability to work as part of an integrated multi-skilled team.

Evidence of self-development and self-motivation

Strong attention to detail, able to work accurately, identifying errors and the ability to transfer accurate information.

Commitment towards working towards and meeting deadlines.

Ability to undertake training outside of normal working hours if necessary

Interested in developing knowledge and skills and taking on additional learning

Additional
Commitment to continuing education and professional development

A recognition of the im

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