Clinical Coder including reception support in Ipswich

Clinical Coder including reception support

Job Summary The post holder will work as part of the practice team, responsible for the accurate and timely summarising and clinical coding of patient correspondence. The role will involve reviewing incoming correspondence, identifying relevant clinical information, taking appropriate action, and ensuring that items requiring clinical input are promptly forwarded to the appropriate member of the Clinical Team. The post holder will contribute to maintaining accurate, up-to-date and high-quality patient records, while ensuring that all correspondence is processed efficiently, confidentially and in accordance with practice procedures and NHS requirements.

Key Responsibilities

• Accurately code diagnoses, symptoms, procedures, investigations and clinical information using SNOMED CT and other relevant coding systems.
• Review and code information from patient consultations, clinical letters, hospital correspondence, test results and discharge summaries.
• Ensure patient records are complete, accurate, up to date and appropriately coded.
• Identify missing or unclear clinical information and liaise with GPs and other clinicians where clarification is required.
• Support the practice with QOF, enhanced services, IIF and other contractual reporting requirements.
• Maintain confidentiality and comply with GDPR, information governance and practice policies.
• Identify coding discrepancies or duplicate/inaccurate entries and make appropriate corrections.
• Support the practice in achieving high-quality clinical data and accurate reporting.
• Keep up to date with changes to coding standards, NHS requirements and primary care contractual requirements.
• Work closely with GPs, practice nurses, administrators and the wider practice team to improve the quality of clinical records.
• Contribute to continuous improvement of clinical coding processes and data quality within the practice.
• Correspond with patients and hospital trusts regarding relevant clinical and administrative matters.
• Reception support, including booking nursing appointments, responding to patient enquiries, signposting patients to appropriate healthcare services, and providing guidance and support with the use of AskMyGP.
• Take opportunities (make every contact count MECC) as appropriate to remind patients to book checks, for example chronic disease annual reviews, childhood immunisations, cervical screening

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 will have access to confidential information relating to patients and their carers, 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 and 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 recognises 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 Monthly training sessions as necessary

Quality

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 cars 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

Equal Opportunities

Cardinal Medical Practice is an equal opportunities employer and you will be expected to comply with all relevant policies and procedures in this area together with all other policies and procedures as initiated by the practice.

Work Visa/Permits/Leave to Remain

If you are a non-resident of the United Kingdom or European Economic Union, you are required to have a valid work visa and leave to remain in the UK, which is renewed as required. The Practice is unable to employ or continue to employ you if you require but do not have a valid work visa and/or leave to remain in the UK.

Code of Conduct

All staff are required to work in accordance with the code of conduct for their professional group (e.g. Nursing and Midwifery Council, Health Professions Council, General Medical Council, NHS Code of Conduct for Senior Managers).

Infection Control

It is the responsibility of all staff, whether clinical or non-clinical, to familiarise themselves with and adhere to current policy in relation to the prevention of the spread of infection. Clinical staff, on entering and leaving clinical areas and between contacts with patients, must apply alcohol gel to their hands and also wash their hands frequently with soap and water. Staff are required to communicate any infection risks to the Infection Control lead.

Complaints

From time to time, complaints may occur, no matter how professional the approach of our staff. All complaints are investigated promptly, and the full co-operation of staff is required. The current guidelines amplify the above points with policies and procedures explained.

Clinical Governance and Risk Management

The Practice believes everyone has a role to play in improving and contributing to the quality of care provided to our patients. As an employee of the practice you are expected to take a proactive role in supporting the Practices clinical governance agenda by: Taking part in activities for improving quality such as clinical audit Identifying and managing risks through incident and near miss reporting and undertaking risk assessments Following polices, guidelines and procedures Maintaining continued professional development Clinical staff making entries into patient health records are required to follow any Practice standards of record keeping

Information Quality Assurance

As an employee of the Practice it is expected that you will take due diligence and care in regard to any information collected, recorded, processed or handled by you during the course of your work and that such information is collected, recorded, processed and handled in compliance with Practice requirements and instructions.

Freedom of Information

The post holder should be aware of the responsibility placed on employees under the Freedom of Information Act 2000 and is responsible for helping to ensure that the Practice complies with the Act when handling or dealing with any information relating to Practice activity.