Job summary We are offering an exciting opportunity for a Clinical Coder & Summariser to join our successful & progressive group of five practices in the Walsall area. You will be responsible for reading electronic & hard copy correspondence; coding or linking diagnoses to record on patients records, coding relevant investigations, and actioning requests as necessary. The role also involves compiling a comprehensive, chronological medical summary from the patient record and inputting into electronic records utilising the Good Practice guidelines & Umbrella Medical Summarising Protocol. Moving forwards, you will have the chance to be involved in the Lloyd George envelope digitisation of notes project. The successful candidate will ideally have a clinical background but applicants will be considered if they have previous experience of working in a clinical setting or of using clinical coding systems. The successful candidate will also have Effective communication skills Good IT skills (EMISweb experience an advantage) Knowledge of medical terminology and read code systems Ability to use own judgement and work without direct supervision to determine workload priorities and achieve targets/deadlines High level of attention to detail Main duties of the job You will be responsible for reading electronic & hard copy correspondence; coding or linking diagnoses to record on patients records, coding relevant investigations, and actioning requests as necessary. The role also involves compiling a comprehensive, chronological medical summary from the patient record and inputting into electronic records utilising the Good Practice guidelines & Umbrella Medical summarising protocol. Moving forwards, you will have the opportunity to be involved in the Lloyd George envelope digitisation of notes project. About us Umbrella Medical is a growing partnership with a very strong emphasis on providing high quality accessible care. We are currently CQC OUTSTANDING (2 practices) and continue to build on that foundation. We recognise that General Practice is changing and in order to continue to provide excellent care we are offering the above position. Date posted 09 April 2025 Pay scheme Other Salary Depending on experience Contract Permanent Working pattern Full-time, Part-time Reference number A0260-23042025 Job locations Mossley Fields Surgery 3 Fisher Road Walsall WS3 2TA Umbrella Medical 1 Hatherton Street Walsall WS11AF The Broadway Medical Centre 213 Broadway Walsall WS13HD Holland Park Surgery Chester Road North Walsall WS87JB Job description Job responsibilities Major duties and responsibilities of the post: Summarising: From patient records identify relevant medical events, read code and log into the computer, categorising into significant or minor events Sort Lloyd George cards or A4 records into date order; retrieve relevant information, read code into computer and tag cards Place letters and reports into date order, retrieve relevant information, code to computer and tag Follow up missing records with previous GP and Medical Records Department Place appropriate information into relevant templates Follow up on any defaults i.e. cervical screening, asthma checks, diabetic reviews, retinopathy screening, medication reviews and immunisations and contact reception to book if required Update new diabetic patients to the diabetic retinopathy screening service Report learning disabilities patients to the Learning Disabilities Nursing Team to ensure that they are known to service and coded as needing an annual LD review and contact reception to book if required Prioritise workload as necessary, ensuring children, vulnerable adults or those with significant health problems are summarised first When summarising a child check household in case of possible child/ adult safeguarding concerns Ensure a childs household address matches exactly to that of Parent/Carer or any other adult living at the same address Report any child or adult safeguarding concerns to the appropriate lead/clinician Ensure any extraneous material in records is shredded prior to disposal Filing and retrieval of paperwork Ensure pregnant patients are coded as pregnant and ensure they have a midwife appointment booked Record and date childrens current school from new patients questionnaire Verify forms that express dissent to the: Summary Care Record dataset upload, Care Data Service and data to and from Health and Social Care to be used and code as required Obtain any past family medical history from records and code to computer appropriately Record any patient allergies identified appropriately Monitoring the progress of notes summarising against Umbrella Medical targets/deadlines Process and verify the GP to GP transfer of electronic and paper records for new patients to the practice, ensuring outstanding referrals and results are actioned appropriately Ensure that medications transferred via GP to GP are stopped and recorded and if needed a new patient medication review is booked by reception Verify that all records belong to the patient, and if not return to the appropriate organisation Post Reading Read electronic and hard copy of incoming correspondence; code or link diagnosis to record in patients problem page, code relevant investigations, and action requests as necessary Ensure relevant investigations necessary for a diagnosis such as MRI/ CT scan are recorded when coding problems such as TIA/Stroke/STEMIs Send tasks as relevant i.e. book appointment with doctor to reception Send reports/results as requested Check addresses are correct on clinic letters and notify reception if different to the address we hold to confirm with the patient and appropriate action can be taken Inform the practices Cancer Champion of a new diagnosis of cancer so the patient can receive the appropriate support Tidy up problem page/patient warning whenever possible by removing unnecessary or outdated information Ensure children subject a to child protection plan warning is removed when necessary by recording corresponding code when the child is no longer on register Add code/note to all other family members when a child is subject to a child protection plan or there is domestic abuse in household Code and monitor childrens DNA and vulnerable adults at hospital appointments, and inform the appropriate clinician/lead if necessary Auditing on an adhoc basis historical codes as required to ensure validity of coding Notify relevant summariser/lead on GSF if a patient is end of life so they can be put on the GSF register Any other duties considered by Umbrella Medical to be appropriate to the post Job description Job responsibilities Major duties and responsibilities of the post: Summarising: From patient records identify relevant medical events, read code and log into the computer, categorising into significant or minor events Sort Lloyd George cards or A4 records into date order; retrieve relevant information, read code into computer and tag cards Place letters and reports into date order, retrieve relevant information, code to computer and tag Follow up missing records with previous GP and Medical Records Department Place appropriate information into relevant templates Follow up on any defaults i.e. cervical screening, asthma checks, diabetic reviews, retinopathy screening, medication reviews and immunisations and contact reception to book if required Update new diabetic patients to the diabetic retinopathy screening service Report learning disabilities patients to the Learning Disabilities Nursing Team to ensure that they are known to service and coded as needing an annual LD review and contact reception to book if required Prioritise workload as necessary, ensuring children, vulnerable adults or those with significant health problems are summarised first When summarising a child check household in case of possible child/ adult safeguarding concerns Ensure a childs household address matches exactly to that of Parent/Carer or any other adult living at the same address Report any child or adult safeguarding concerns to the appropriate lead/clinician Ensure any extraneous material in records is shredded prior to disposal Filing and retrieval of paperwork Ensure pregnant patients are coded as pregnant and ensure they have a midwife appointment booked Record and date childrens current school from new patients questionnaire Verify forms that express dissent to the: Summary Care Record dataset upload, Care Data Service and data to and from Health and Social Care to be used and code as required Obtain any past family medical history from records and code to computer appropriately Record any patient allergies identified appropriately Monitoring the progress of notes summarising against Umbrella Medical targets/deadlines Process and verify the GP to GP transfer of electronic and paper records for new patients to the practice, ensuring outstanding referrals and results are actioned appropriately Ensure that medications transferred via GP to GP are stopped and recorded and if needed a new patient medication review is booked by reception Verify that all records belong to the patient, and if not return to the appropriate organisation Post Reading Read electronic and hard copy of incoming correspondence; code or link diagnosis to record in patients problem page, code relevant investigations, and action requests as necessary Ensure relevant investigations necessary for a diagnosis such as MRI/ CT scan are recorded when coding problems such as TIA/Stroke/STEMIs Send tasks as relevant i.e. book appointment with doctor to reception Send reports/results as requested Check addresses are correct on clinic letters and notify reception if different to the address we hold to confirm with the patient and appropriate action can be taken Inform the practices Cancer Champion of a new diagnosis of cancer so the patient can receive the appropriate support Tidy up problem page/patient warning whenever possible by removing unnecessary or outdated information Ensure children subject a to child protection plan warning is removed when necessary by recording corresponding code when the child is no longer on register Add code/note to all other family members when a child is subject to a child protection plan or there is domestic abuse in household Code and monitor childrens DNA and vulnerable adults at hospital appointments, and inform the appropriate clinician/lead if necessary Auditing on an adhoc basis historical codes as required to ensure validity of coding Notify relevant summariser/lead on GSF if a patient is end of life so they can be put on the GSF register Any other duties considered by Umbrella Medical to be appropriate to the post Person Specification Qualifications Essential Good Standard of education including GSCE pass grade in English Language and Maths Desirable Nursing/medical qualification Experience Essential Experience of working in General Practice or the NHS Experience of using a clinical system Desirable Previous experience of working as clinical summariser/coder of medical notes within the NHS Experience of working with EMIS Web Knowledge & Skills Essential Medical Terminology Understanding of the read code system/SNOMED coding Effective Communication Skills Analytical skills Excellent telephone manner Good IT Skills Desirable Able to multi-task High level of computer literacy Personal Competencies and Qualities Essential Understanding, acceptance and adherence to the need for strict confidentiality. Ability to use own judgement and work without direct supervision to determine workload priorities. Ability to recognise the severity of different medical conditions and the urgency of the actions they require Ability to work as part of a multi skilled team. Methodical approach to work and ability to meet targets/deadlines Self-motivated Willing to take part in training and personal development High attention to detail Friendly and articulate Smart appearance Desirable Able to cope well with working in a changing and demanding environment Person Specification Qualifications Essential Good Standard of education including GSCE pass grade in English Language and Maths Desirable Nursing/medical qualification Experience Essential Experience of working in General Practice or the NHS Experience of using a clinical system Desirable Previous experience of working as clinical summariser/coder of medical notes within the NHS Experience of working with EMIS Web Knowledge & Skills Essential Medical Terminology Understanding of the read code system/SNOMED coding Effective Communication Skills Analytical skills Excellent telephone manner Good IT Skills Desirable Able to multi-task High level of computer literacy Personal Competencies and Qualities Essential Understanding, acceptance and adherence to the need for strict confidentiality. Ability to use own judgement and work without direct supervision to determine workload priorities. Ability to recognise the severity of different medical conditions and the urgency of the actions they require Ability to work as part of a multi skilled team. Methodical approach to work and ability to meet targets/deadlines Self-motivated Willing to take part in training and personal development High attention to detail Friendly and articulate Smart appearance Desirable Able to cope well with working in a changing and demanding 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. Employer details Employer name Umbrella Medical Address Mossley Fields Surgery 3 Fisher Road Walsall WS3 2TA Employer's website https://www.umbrellamedical.co.uk (Opens in a new tab)