About this role
Job summary
The Clinical Coder is responsible for accurately reviewing and coding clinical information within patient records, ensuring that diagnoses, investigations, procedures, and other relevant clinical activity are recorded using the appropriate NHS coding systems.
The role involves reviewing clinical documentation, identifying relevant information for coding, and ensuring records are complete, accurate, and up to date. The Clinical Coder works closely with GPs and the wider practice team to clarify any missing or unclear information and supports the accurate recording of patient care.
The role also contributes to the accuracy of practice data used for clinical monitoring, reporting, Quality and Outcomes Framework (QOF), enhanced services, and other NHS requirements. Maintaining patient confidentiality, information governance, and high standards of accuracy is an essential part of the role.
Main duties of the job
The main duties of the clinical coder include reviewing patient records and clinical documentation
Accurately coding diagnoses investigations procedures and clinical activity using appropriate NHS coding systems
Ensuring patient records are accurate complete and up to date
Identifying missing or unclear clinical information and liaising with clinical staff when clarification is required
Supporting the practice with accurate clinical data for QOF enhanced services and NHS reporting requirements
Maintaining patient confidentiality and complying with information governance requirements
Working closely with GPs and the wider practice team to support accurate clinical record keeping
Ensuring all coding is completed accurately and within required timescales
About us
We are a multidisciplinary NHS General Practice providing comprehensive primary care services to our registered patient population. The practice operates with a diverse and experienced clinical and administrative team, working collaboratively to provide safe, effective, and patient-centred care.
Our clinical team consists of 4 GP Partners, 2 Salaried GPs, 3 Advanced Nurse Practitioners (ANPs), 3 Practice Nurses, 2 Healthcare Assistants (HCAs), 2 Clinical Pharmacists, 1 Pharmacy Technician, 1 Paramedic, 1 Mental Health Practitioner, 1 Paediatric Specialist Practitioner, 1 Practice Manager, 1 Digital and Practice Manager (DPM), and 1 Care Coordinator.
The practice is supported by a strong administrative team comprising 4 Medical Secretaries, 3 Administrators, and 11 Receptionists. All members of the team work closely together to ensure the smooth running of the practice, effective communication, accurate record keeping, and delivery of high-quality patient care.
Our multidisciplinary approach enables us to provide a broad range of services within the practice, while supporting GPs and other clinicians in managing patients effectively and reducing pressure on primary care services.
Job description Job responsibilities
The clinical coder is responsible for reviewing patient records and clinical documentation and accurately recording relevant clinical information using appropriate NHS coding systems
The role involves reviewing consultations diagnoses investigations procedures referrals and other clinical activity to ensure that patient records are accurate complete and up to date
The clinical coder works closely with GPs clinicians and practice staff to identify missing or unclear information and obtain clarification where required
The role supports the practice by ensuring accurate clinical data is recorded for QOF enhanced services clinical audits and NHS reporting requirements
The clinical coder is responsible for maintaining high standards of accuracy and confidentiality and must comply with information governance requirements and practice policies
The role requires attention to detail good organisational skills and the ability to work independently while managing workload and meeting required timescales
The clinical coder contributes to the effective management of patient information and supports the wider practice team in maintaining high quality clinical records
Person Specification
Experience Essential
Experience of working in a general practice or primary care environment Experience of reviewing and coding clinical information from patient records Experience of using clinical coding systems and electronic patient records Experience of working with confidential and sensitive patient information Experience of working accurately and maintaining high standards of data quality Experience of working independently and managing workload to meet deadlines Experience of liaising with GPs clinicians and members of the wider practice team Experience of identifying missing or unclear clinical information and seeking clarification when required
Desirable
Previous experience working as a clinical coder within general practice Experience using EMIS and Anima clinical systems Experience of coding diagnoses investigations procedures referrals and other clinical activity Experience of supporting QOF and enhanced services Experience of clinical audit and data quality improvement Experience of reviewing patient records to identify uncoded or incorrectly coded clinical information Experience of working with multidisciplinary teams within primary care Experience of NHS data reporting requirements Experience of identifying trends and discrepancies within clinical data Experience of maintaining accurate and timely clinical records
Qualifications Essential
Relevant clinical coding training or qualification Knowledge of NHS clinical coding systems and terminology Good standard of general education including English and mathematics Relevant experience in general practice or a healthcare environment Understanding of medical terminology and clinical documentation Knowledge of confidentiality and information governance requirements Evidence of ongoing learning and professional development
Desirable
Formal qualification in clinical coding Additional training in NHS clinical coding Knowledge of SNOMED CT and Read Codes Knowledge of primary care clinical coding and data recording Understanding of QOF and enhanced services Knowledge of EMIS and Anima clinical systems Knowledge of primary care systems and electronic patient records Previous experience of clinical coding within general practice Evidence of continuing professional development Understanding of clinical audit and data quality
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 Peelhouse Medical Plaza
Address Peelhouse Lane
Widnes
Cheshire
WA8 6TN
United Kingdom
Employer's website https://www.peelhouse-medical-plaza.nhs.uk/ (Opens in a new tab)