Clinical coder/Medical Summariser in London

Overview

In this role you will review incoming medical records and related correspondence to produce accurate patient histories and coded data. You will work with GPs and the broader practice team to ensure records are up-to-date and support safe patient care. The position involves data quality control, coding, and summarising to meet practice targets, within a supportive, teaching-oriented Primary Care environment.

Responsibilities

• Review new patient medical records and summarise relevant past medical history
• Read and process hospital letters, discharge summaries, outpatient correspondence, investigation results and other clinical documentation
• Identify and accurately record diagnoses, procedures, medications, allergies, significant medical history and other relevant clinical information
• Apply appropriate clinical codes in accordance with practice procedures and established coding standards
• Ensure patient records are maintained accurately and consistently
• Identify missing, unclear or potentially significant information and refer appropriately to the relevant clinician or practice team member
• Process incoming clinical correspondence within agreed timescales
• Maintain strict patient confidentiality and comply with GDPR, NHS information governance and practice policies
• Follow practice procedures relating to safeguarding, data protection, information security and patient safety
• Liaise with GPs, nurses, administrative staff and other members of the multidisciplinary team when clarification or further action is required
• Maintain a high level of accuracy while working to agreed deadlines and workload requirements
• Undertake any other appropriate duties relevant to the role and level of responsibility

Key requirements

• GCSEs or equivalent, including English and Mathematics
• Qualification or training in medical terminology, medical administration or clinical coding
• Evidence of good IT and administrative skills
• Ability to accurately interpret and record information from medical documentation
• Desirable: NVQ/QCF Level 2 or 3 in Business Administration, Health and Social Care, or related subject
• Desirable: Knowledge or training in SNOMED CT, Read coding, EMIS or System One
• Essential: Good understanding of medical terminology
• Essential: Excellent attention to detail and accuracy
• Essential: Good written and verbal communication skills
• Essential: Strong organisational and time-management skills
• Essential: Ability to work independently and manage workload effectively
• Essential: Good IT skills and confidence using electronic clinical records
• Essential: Understanding of confidentiality and protecting patient information
• Essential: Ability to work as part of a multidisciplinary team
• Desirable: Previous NHS or primary care-related training
• Desirable: Experience with reviewing and summarising medical records
• Desirable: Knowledge of clinical coding systems such as Read Codes or SNOMED CT
• Desirable: Experience using EMIS or System One

• attention to detail
• strong organisational skills
• good communication (written and verbal)
• EMIS Web
• GP Links
• Read coding