Medical Coder and summariser

Job description

Job responsibilities

Following Practice policies, protocols and guidelines, duties will include:

Summarising:

• Responsible for ensuring patient medical records are kept current, in chronological order, in good repair and continually archiving the older records, monitoring their safe storage.

• Summarize patient clinical records and enter the summary onto the electronic patient record; in a timely manner according to current guidance and following the summarizing protocol.

• Support transfer of records and data to partner health care providers.

• Ensuring full knowledge of the Read Codes system.

• Inputting data using the Read Codes system.

• Auditing data collection to ensure Practice standards are met.

• Monitoring the progress of notes for summonsing

• Use clinical knowledge to escalate any anomalies in patient notes

• Ensure information within the patient file, which is not required to be kept, is disposed of appropriately.

• Sorting patient records and letters in preparation of summarizing when required

• Ensure all new medical records are sorted, ideally within 8 weeks of the notes being received at the practice, or as soon as possible thereafter. Archiving as required

• Respond to all queries and requests for assistance from staff and ensure that any records that are identified are summarized in a timely manner

Clinical Coding:

• To ensure accurate coding of any written clinical or electronic correspondence onto the patient notes

• To have in-depth knowledge of the scanning pathway and direct any relevant letters to the correct clinical group

• Ensure familiarity with the current pathway and be proactive in following this process

• Liaise with the performance lead as regards any problems that occur with the scanned/electronic documents

Admin Duties

• Daily administration of NHS Net file

• To deal with any electronic and Out of Hours correspondence received daily

• Emis Web Workflow task files (this includes Shared Care Records (SCRs), Patient Facing Services Messages, GP2GP etc.)

PCSE Deliveries and Correspondence:

• To ensure that all information received from PCSE is dealt with on a weekly basis

• To record the arrival of all new records and arrange the input of any relevant information

• To facilitate the summarizing of these records in accordance with the QUOF targets

• To review and distribute to the relevant departments all incoming mail received in the bag

• To arrange cover for dealing with the PCSE deliveries and correspondence during holiday periods

• Any other appropriately delegated tasks

Practice Development and Clinical Governance:

• To participate in primary healthcare team meetings

• To provide data, as requested, for Practice Development Plans and reports

• To collect data as part of clinical and organizational audit process

• To be aware of Practice Policies on risk management/incident reporting and health and safety and operate appropriate procedures for minimizing risk

• To be aware of issues related to own development and be committed to participate in training and education

• To operate the practice-based complaints procedure and respond/forward complaints as appropriate

Operation of the Computer/Telephone System:

• Operate Workflow daily

• Ensure total familiarity with the database system

• Comply with all systems for data security and protection

• Receive and make calls as required

Health and Safety Responsibilities:

• Employees must take reasonable care for the Health and Safety of him/herself and/or others who may be affected by his/her acts or omissions at work

• Must co-operate with the Employer in so far as necessary to enable that duty or requirement to be performed or complied with

• No person shall intentionally or recklessly interfere with or misuse anything provided in the interests of Health, Safety or Welfare

Confidentiality:

• All information relating to patients and staff gained through your employment and after leaving employment with Brownlow Health is confidential. Disclosure to any unauthorized person is a serious disciplinary offence or may result in litigation

This job description is not intended to be exhaustive but to indicate the main areas of responsibility. It may be changed after consultation with the post-holder

Person Specification

Personal skills and abilities

Essential

• A friendly and approachable manner, with good people skills, showing understanding, care, and assertiveness when appropriate.
• The ability to communicate clearly and effectively (both verbal and written) with a wide range of individuals.
• Good administrative and organisational skills, with the ability to prioritise work.
• A conscientious approach and commitment to working in an adaptable and flexible manner.
• The ability to work calmly and effectively and deal with multiple demands even when busy.
• The ability to cope with occasional exposure to challenging behaviour, distressing circumstances, or emotional events.
• The ability to deal with personal information sensitively and respect people's right to confidentiality.
• The ability to work positively as a member of a busy team.
• The ability to give good and regular attendance.
• The ability to work on own initiative.

General

Essential

• A commitment to support the delivery of the best possible service to a diverse inner-city population

Knowledge, training and experience

Essential

• Coding & Summarising experience
• Clear understanding of Emis & Workflow
• A sound general education to GCSE level or equivalent, or equivalent working experience.
• A good standard of grammar and spelling in the English language.
• The ability to produce accurate and thorough work, including alphabetical filing.
• Experience of using computers, with good keyboard skills.
• Excellent attention to detail.

Desirable

• Training or qualifications in customer service, IT, or other related areas.
• Experience of summarising and read coding in the NHS.
• Experience of dealing with the public.
• Experience of working with Emis and workflow

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

Brownlow Group Practice

Address

Brownlow Health @ Pembroke Place

70 Pembroke Place

Liverpool

Merseyside

L69 3GF

Employer's website

https://www.brownlowhealth.co.uk/ (Opens in a new tab)