About this role
Job summary
Can you read a hospital letter, identify what matters and make sure the right information reaches the patient record and the right person?
The Cornerstone Practice is looking for a Clinical Coding Administrator to provide maternity cover within our clinical administration team. This is careful, focused work that directly supports safe patient care.
You will read incoming hospital letters and discharge summaries, identify diagnoses, procedures, results and follow-up actions, and record the relevant information accurately in SystmOne. You will also highlight medication changes, appointment or referral requests and anything requiring GP review, then send it to the correct person.
You must be comfortable working with detailed clinical information, following clear protocols and knowing when to stop and ask rather than guess. Previous experience of clinical coding or processing medical correspondence would be a strong advantage. Training will be provided on Cornerstone's local procedures.
This is a fixed-term maternity-cover post running until 30 June 2027. The post is for 8 hours per week. The working pattern and rate of pay are to be confirmed before publication.
We care for approximately 9,500 patients and use SystmOne. An immediate start is available.
Main duties of the job
You will process and code incoming clinical correspondence accurately and safely. Your work will include:
Reading hospital letters, clinic letters and discharge summaries in full
Identifying diagnoses, procedures, results and information that must be added to the patient record
Entering accurate coded information in SystmOne using the correct date, severity and summary status
Checking for existing problems and linking new information to the correct patient problem
Linking procedures to the relevant diagnosis or condition
Identifying medication changes, appointment requests, referrals and other actions
Highlighting and forwarding actions to the correct GP, clinician or administration team
Recording clear notes so the recipient understands what action is required
Processing documents that require no further action and filing them safely
Following practice coding guides, templates and document-management procedures
Recognising unclear, conflicting or unfamiliar information and asking for advice rather than guessing
Maintaining accurate, timely and confidential patient records
About us
The Cornerstone Practice is based in the centre of March and cares for approximately 9,500 patients. We use SystmOne and Anima.
Our team includes GP partners, salaried GPs, advanced practitioners, treatment-room nurses, healthcare assistants, a mental health practitioner and experienced reception and administration colleagues. We also work with pharmacy, physiotherapy and social-prescribing colleagues.
The clinical administration team helps turn a large amount of incoming information into accurate, useful patient records. The work is detailed and sometimes complex, but you will have clear local guidance and colleagues to ask when something is not straightforward.
Job description Job responsibilities
The post-holder will support the safe and timely management of incoming clinical correspondence. They will work within their training, competence, practice protocols and information-governance requirements at all times.
Document processing and coding Open and process correspondence received through SystmOne Document Management and the agreed team workflow
Read the complete document before deciding what information or action it contains
Use the practice Document Processing template and enter the correct clinic, admission, discharge and scanned dates
Code relevant diagnoses, conditions, procedures, results, observations and lifestyle information accurately
Apply the correct problem status, severity and patient-summary settings in line with the practice coding guide
Check for existing coded problems to avoid unnecessary duplication and link information appropriately
Make problems inactive when the correspondence confirms that this is appropriate and permitted by local guidance
Follow specific practice routes for documents that must be sent to a named clinician or team
Actions and escalation Identify and clearly mark medication changes, GP actions, appointment requests and referral requests
Forward each action to the correct person with a clear explanation of what is required
Send a document to more than one recipient when separate actions are required
Check again for outstanding actions before filing any document
Do not code or file information when its meaning, date, diagnosis or required action is unclear
Escalate urgent, unexpected or clinically significant information promptly using the agreed process
Report errors, near misses and recurring document-quality problems to the appropriate manager
Records confidentiality and teamwork Maintain accurate, clear and timely electronic patient records
Protect patient and practice information and follow confidentiality, data-protection and information-governance requirements
Work closely with GPs, clinicians and administrative colleagues to resolve queries
Manage the allocated workload in priority order and communicate promptly if work is delayed
Attend induction, mandatory training, appraisal and relevant team meetings
Undertake other reasonable administrative duties appropriate to the role
Person Specification
Experience Essential
Experience of accurate administrative or data-processing work Able to read detailed documents, identify relevant information and follow written procedures Strong attention to detail and consistently accurate data entry Confident using computers and able to learn electronic patient-record systems Able to organise a workload, work to deadlines and manage competing priorities Able to recognise uncertainty and seek advice rather than make assumptions Clear written communication and the ability to record concise action notes Understands the importance of confidentiality and handling sensitive health information Able to work independently while remaining part of a wider team Reliable, methodical and willing to take responsibility for the accuracy of their work
Desirable
Experience of accurate administrative or data-processing work Able to read detailed documents, identify relevant information and follow written procedures Strong attention to detail and consistently accurate data entry Confident using computers and able to learn electronic patient-record systems Able to organise a workload, work to deadlines and manage competing priorities Able to recognise uncertainty and seek advice rather than make assumptions Clear written communication and the ability to record concise action notes Understands the importance of confidentiality and handling sensitive health information Able to work independently while remaining part of a wider team Reliable, methodical and willing to take responsibility for the accuracy of their work
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 The Cornerstone Practice
Address Elwyn Road
March
Cambs
PE15 9BF
United Kingdom
Employer's website https://www.cornerstoneandmercheford.nhs.uk/ (Opens in a new tab)