Job summary
The Maltings Surgery has a vacancy for an experienced Clinical Coder / Summariser. The post is open to full time or part time applicants and flexible working will be considered. We are looking for applicants with a healthcare background as medical knowledge and experience is essential to this position. With experience of IT/computer and coding, and knowledge of Emis clinical system or other clinical system and Snomed coding is desirable.
You will be joining two summarising colleagues as part of a long established summarising team, and benefit from a fully supportive, cooperative working environment, with a GP Lead who provides support and meets with the team regularly.
Main duties of the job
The core work is summarising and coding current discharge summaries and hospital clinic letters, both paper and electronic. Summarising of salient information and entering data onto EMIS Web clinical system. Summarising of paper medical records and managing clinical system data form various sources.
About us
We serve 18,000 patients from the heart of St. Albans city centre we are part of the Abbey Primary Care Network (PCN) formed on a mutual values basis, between two collaborative neighbouring GP Practices in St. Albans and London Colney. We have recently set up a young persons clinic.
The Practice has a strong emphasis on teaching and training with medical students and GP registrars and other training roles.
The wider team consists of GPs, Nurses, Paramedics, other ARRS clinical roles, reception team, management and secretarial teams.
Job description
Job responsibilities
The following are the core responsibilities of the Clinical Coder and medical Summariser;
Summarising salient points (from patients previous practice summaries, checking through for medications, immunisations, chronic diseases, ongoing problems) and entering data on EMIS Web.
Summarising new patient records to a high standard and within agreed timescales; Restructuring existing computerised notes; Filing and retrieving paperwork; Produce a comprehensive electronic summary using Emis Web; Maintaining structure when recording new information; Assisting GPs and other health professionals with queries relating to medical records; scanning daily for incoming patient documentation in line with the practice procedure; To work as a member of the clinical coding/summarising team, with responsibility for own areas, inputting coded data into the clinical system.
Coding from information gathered from a number of sources including patient notes, discharge forms, both manual and electronic, and other clinical information captured on a variety of sources.
This will also involve running computer searches on to identify missing information; To work with other administrators and healthcare professionals to provide a high quality service to our patients; To ensure clinical coding is recorded in a timely and accurate manner in accordance with both national and local guidelines and standards; Snomed coding the information into the practice clinical system being aware of QOF requirements; To record sensitive information accurately status, child protection register and safeguarding issues; Auditing data collection standards in the practice in clinical and administrative staff; Participate in audit where appropriate; To maintain clinical coding skills and participate in internal and external training programmes as required for both refresher and specialist clinical coding courses and work toward a high standard of coding; To extract, interpret and independently code clinical information from clinical letters and Discharge summaries from Hospitals and Clinics To participate in quality improvement initiatives, identifying areas where the processes used within the coding function can be improved and assist in implementing; To feedback coding information to senior management and to improve the quality and completeness of documents or clinical notes; To work in accordance with the service specification and clinical key performance indicators; To work In line with national, local and organisational priorities in order to affect good access for patients and to maximize activity and opportunity; Code all documents that are imported through the document manager on Emis; Review records to identify any apparent missing information childhood immunisations and liaise with PCSE or other relevant NHS department to complete the record as far as possible; File and store records as required; Photocopy documentation as required; Any other duties as may be determined from time to time commensurate with the range of activities described above
There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels; Receiving and checking clinical notes for newly registered patients.
Person Specification
Qualifications
Essential
1. Educated to GCSE level or equivalent
Desirable
2. GCSE Mathematics and English (C or above)
3. NVQ Level 2 in Health and Social Care
4. Medical records summarisation qualification
Experience
Essential
5. Experience of working in a healthcare setting
6. Experience of clinical coding
Desirable
7. Experience of working in a GP practice
Skills
Essential
8. Excellent communication skills (written and oral)
9. Strong IT skills
10. Clear, polite telephone manner
11. Competent in the use of Office and Outlook
12. Ability to work as a team member and autonomously
13. Good interpersonal skills
14. Problem solving and analytical skills
15. Ability to follow policy and procedure
16. Personal qualities
17. Polite and confident
18. Flexible and cooperative
19. Motivated
20. Forward thinker
21. High levels of integrity and loyalty
22. Sensitive and empathetic in distressing situations
23. Ability to work under pressure