Job summary
An excellent opportunity has arisen to join our friendly, existing Clinical Coding team, at our busy, forward thinking GP Practice.
The successful candidate will be responsible for summarising and coding medical information onto patients electronic healthcare records using the NHS system, SystmOne.
Main duties of the job
The
duties and responsibilities to be undertaken by members of the clinical coding
may be varied from time to time under
the direction of the Management team. This will include:
Scanning of any clinical letters
received from all external organisations and filing all electronically
received mail into patient records and to be coded in accordance with
practice policy.
Identifying relevant clinical
information documented in patient correspondence, coding appropriately and
completing any detailed actions.
Input and extract data as required
to support practice reports.
File and store records as required.
Input data into the patients
healthcare records as necessary.
Carry out system searches as
requested and conduct audits and coding reviews to ensure all
documentation is accurate and precise.
To attend regular coder meetings
for updates and sharing of information.
Maintain a clean, tidy, effective
working area at all times.
Support all clinical staff with
general administrative tasks as requested.
To
adhere to the practices clinical coding and summarising policy.
About us
Mowbray Group surgeries comprise of Mowbray House Surgery in Northallerton and a branch surgery in Hutton Rudby.
Our dedicated doctors are supported by a full support team of health and administrative professionals including practice, district and specialist nurses, health care assistants, dispensers, and a physiotherapist.
Our aim is to to provide high quality primary care services to the registered patients at the practice.
These services will be provided in a safe and secure environment with the patients well-being our top priority.
We will endeavour to ensure all team membersare appropriately trained, well-motivated and appraised on an annual basis.
As a training organisation for Registrars and F2 doctors, the practice will endeavour to promote clinical excellence and a proper educational experience for these future GPs and doctors in other specialities.
We are an accredited Veteran Friendly Practice.This means we have dedicated clinicians who have specialist knowledge and experience of service related health conditions.
Job description
Job responsibilities
Mowbray House Surgery
Job Description
Job Title -Clinical Coder
Responsible to -Office Team Leader
Hours -Up to full time
Job Summary
The purpose of the role is to
Be responsible for the clinical coding of relevant information into the patient's electronic healthcare record using SystmOne
Support our multidisciplinary team, providing administrative support as required, in line with the needs of the practice.
Summarise medical records.
Duties and Responsibilities
The duties and responsibilities to be undertaken by members of the clinical coding team may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the Management team
- Scanning of any clinical letters received from all external organisations and filing all electronically received mail into patient records and to be coded in accordance with practice policy.
- Identifying relevant clinical information documented in patient correspondence, coding appropriately and completing any detailed actions.
- Input and extract data as required to support practice reports.
- File and store records as required.
- Input data into the patients healthcare records as necessary.
- Carry out system searches as requested and conduct audits and coding reviews to ensure all documentation is accurate and precise.
- To attend regular coder meetings for updates and sharing of information.
- Maintain a clean, tidy, effective working area at all times.
- Support all clinical staff with general administrative tasks as requested.
- To adhere to the practices clinical coding and summarising policy.
Confidentiality
- In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
- In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. They may also have access to information relating to the Practice as a business organisation. All such information from any source is to be regarded as strictly confidential
- Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Practice policies and procedures relating to confidentiality and the protection of personal and sensitive data
Health & Safety:
The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy, to include:
- Using personal security systems within the workplace according to Practice guidelines.
- Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.
- Making effective use of training to update knowledge and skills.
- Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
- Reporting potential risks identified.
Equality and Diversity
The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:
- Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with Practice procedures and policies, and current legislation.
- Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
- Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.
Personal/Professional Development
The post-holder will participate in any training programme implemented by the Practice as part of this employment, such training to include:
- Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
- Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.
Quality
The post-holder will strive to maintain quality within the Practice, and will:
- Alert other team members to issues of quality and risk.
- Assess own performance and take accountability for own actions, either directly or under supervision.
- Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.
- Work effectively with individuals in other agencies to meet patients needs.
- Effectively manage own time, workload and resources.
Communication
The post-holder should recognize the importance of effective communication within the team and will strive to:
- Communicate effectively with other team members.
- Communicate effectively with patients and carers.
- Recognize peoples needs for alternative methods of communication and respond accordingly.
Contribution to the Implementation of Services
The post-holder will
- Apply Practice policies, standards and guidance.
- Discuss with other members of the team how the policies, standards and guidelines will affect own work.
- Participate in audit where appropriate.
- Review annually and implement risk assessments
This job description is intended as a guide to the main duties and responsibilities for the post and should not be considered an exhaustive list.
Job description
Job responsibilities
Mowbray House Surgery
Job Description
Job Title -Clinical Coder
Responsible to -Office Team Leader
Hours -Up to full time
Job Summary
The purpose of the role is to
Be responsible for the clinical coding of relevant information into the patient's electronic healthcare record using SystmOne
Support our multidisciplinary team, providing administrative support as required, in line with the needs of the practice.
Summarise medical records.
Duties and Responsibilities
The duties and responsibilities to be undertaken by members of the clinical coding team may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the Management team
- Scanning of any clinical letters received from all external organisations and filing all electronically received mail into patient records and to be coded in accordance with practice policy.
- Identifying relevant clinical information documented in patient correspondence, coding appropriately and completing any detailed actions.
- Input and extract data as required to support practice reports.
- File and store records as required.
- Input data into the patients healthcare records as necessary.
- Carry out system searches as requested and conduct audits and coding reviews to ensure all documentation is accurate and precise.
- To attend regular coder meetings for updates and sharing of information.
- Maintain a clean, tidy, effective working area at all times.
- Support all clinical staff with general administrative tasks as requested.
- To adhere to the practices clinical coding and summarising policy.
Confidentiality
- In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
- In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. They may also have access to information relating to the Practice as a business organisation. All such information from any source is to be regarded as strictly confidential
- Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Practice policies and procedures relating to confidentiality and the protection of personal and sensitive data
Health & Safety:
The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy, to include:
- Using personal security systems within the workplace according to Practice guidelines.
- Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.
- Making effective use of training to update knowledge and skills.
- Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
- Reporting potential risks identified.
Equality and Diversity
The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:
- Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with Practice procedures and policies, and current legislation.
- Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
- Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.
Personal/Professional Development
The post-holder will participate in any training programme implemented by the Practice as part of this employment, such training to include:
- Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
- Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.
Quality
The post-holder will strive to maintain quality within the Practice, and will:
- Alert other team members to issues of quality and risk.
- Assess own performance and take accountability for own actions, either directly or under supervision.
- Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.
- Work effectively with individuals in other agencies to meet patients needs.
- Effectively manage own time, workload and resources.
Communication
The post-holder should recognize the importance of effective communication within the team and will strive to:
- Communicate effectively with other team members.
- Communicate effectively with patients and carers.
- Recognize peoples needs for alternative methods of communication and respond accordingly.
Contribution to the Implementation of Services
The post-holder will
- Apply Practice policies, standards and guidance.
- Discuss with other members of the team how the policies, standards and guidelines will affect own work.
- Participate in audit where appropriate.
- Review annually and implement risk assessments
This job description is intended as a guide to the main duties and responsibilities for the post and should not be considered an exhaustive list.
Person Specification
Experience
Essential
- Essential criteria
- Excellent communication skills, written and oral.
- Excellent IT skills.
- An understanding, acceptance and adherence to the need for strict confidentiality
- Time management and the ability to work to effectively multitask. Ability to use own initiative and problem solve.
- Hard working, adaptable, reliable and resourceful. Willing to work flexible hours as necessary across both surgery sites.
- Educated to GCSE level or equivalent.
- Own transport
- Ability to work as a team member as well as autonomously
- Be entitled to live and work within the UK as we are unable to sponsor. Satisfactory DBS Check.
- Satisfactory references (at least 2)
Desirable
- Desirable criteria
- Experience of working in a healthcare or Social care setting (desirable) Experience of working in General Practice (desirable)
- Experience of clinical systems such as SystmOne
- Full, clean driving licence
Person Specification
Experience
Essential
- Essential criteria
- Excellent communication skills, written and oral.
- Excellent IT skills.
- An understanding, acceptance and adherence to the need for strict confidentiality
- Time management and the ability to work to effectively multitask. Ability to use own initiative and problem solve.
- Hard working, adaptable, reliable and resourceful. Willing to work flexible hours as necessary across both surgery sites.
- Educated to GCSE level or equivalent.
- Own transport
- Ability to work as a team member as well as autonomously
- Be entitled to live and work within the UK as we are unable to sponsor. Satisfactory DBS Check.
- Satisfactory references (at least 2)
Desirable
- Desirable criteria
- Experience of working in a healthcare or Social care setting (desirable) Experience of working in General Practice (desirable)
- Experience of clinical systems such as SystmOne
- Full, clean driving licence
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.
