Clinical Coder & Summariser

Umbrella Medical

The closing date is 23 April 2025

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

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