Senior Clinical Coder

SCOPE AND PURPOSE OF THE ROLE The GP Practice Clinical Coder plays a critical role in accurately assigning medical codes to patient diagnoses, treatments, and procedures within a General Practice (GP) setting. This position requires strong knowledge of medical coding systems, attention to detail, and the ability to interpret medical documentation. The Clinical Coder ensures compliance with coding standards and regulations while maintaining the integrity of patient records.

KEY RESPONSIBILITIES

Review all incoming correspondence filing the document and entering pertinent information into the patients electronically medical record in accordance with the Coding Protocol with attention to QOF. Highlight clinician action and workflow to appropriate clinician or team as per Workflow Protocol. Organise the medical record of patient whom you are coding, to link problem titles. Checking incoming medical records and summarising onto clinical system. Recognise own knowledge limits and seek advice from clinical or administrative colleagues as appropriate. To carry out administrative related tasks as delegated by Clinical Lead and Practice Manager.

Medical Coding

Assign appropriate medical codes to patient diagnoses, treatments, procedures, and other relevant information based on the documentation provided by healthcare professionals. Ensure accurate and consistent coding practices in line with coding guidelines and regulatory requirements.

Documentation Review

Analyse medical records, including physician notes, lab reports, and other clinical documentation, to extract relevant information for coding purposes. Identify any missing or incomplete documentation and seek clarification from healthcare professionals when necessary

Coding Compliance

Adhere to coding standards, guidelines, and regulations such as the NHS Classification Service, Local Medical Committees (LMCs), and relevant healthcare authorities. Stay up to date with changes in coding regulations and ensure compliance within the GP practice.

Quality Assurance

Perform regular audits and quality checks on coded data to identify and resolve any coding discrepancies or errors. Collaborate with healthcare professionals to address any coding-related issues and provide feedback to improve documentation practices.

Coding Systems and Software

Utilize coding systems and software applications (e.g., EMIS, Read Codes) to accurately assign codes and ensure the integrity of coded data. Collaborate with IT staff to address any technical issues or system upgrades related to coding processes.

Training and Education

Stay informed about updates and changes in medical coding guidelines, regulations, and industry best practices. Provide training and education to healthcare professionals and staff members to enhance their understanding of coding practices and documentation requirements.

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 Participate in quality improvement programs such as

EQUIP 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 This job description is not exhaustive but rather a reflection of the current position and the post-holder is expected to view it as a guide rather than an exact description of all duties and responsibilities. It may be subject to variation from time to time as services develop.