Job summary
We are seeking a knowledgeable clinical documentation specialist to oversee our facility's medical recordkeeping practices. In this role, you will be responsible for ensuring that clinical documentation complies with current guidelines, training staff in medical recordkeeping practices, and analyzing medical information.
To ensure success, clinical documentation specialists should exhibit experience in a similar role and sound knowledge of clinical documentation regulations. A first-class clinical documentation specialist should be a medical professional whose expertise translates into sound medical recordkeeping practices.
Main duties of the job
Clinical Documentation Specialist Responsibilities:
Applying knowledge of medical terminology and procedures to evaluate clinical documents.
Collecting medical information from healthcare providers and updating medical records.
Verifying the accuracy of patient medical information and obtaining missing information.
Monitoring diagnoses, treatments, and follow-up entries in medical records.
Clinical Documentation Specialist Requirements:
Registered Nurse/ HCA will be advantageous.
Proficiency in Electronic Medical Record software, such as System one
A minimum of 3 years experience in a similar role.
Advanced knowledge of best practices in medical recordkeeping.
In-depth knowledge of medical terminology, coding, and procedures.
Extensive experience in collecting and interpreting medical information.
Ability to keep informed of advancements and regulations in clinical documentation.
Excellent organizational and communication skills.
About us
Scarsdale Medical Centre is a team focused, friendly practice based in West London. The team consists of 2 GP Partners, 4 Salaried GPs, 1 Practice Nurses, 4 part time Pharmacists, 2 HCAs, and a physicians associate backed by an experienced administration team and a supportive Network. With a multicultural diverse population and a list size of appx 9000, we offer a personalised list system within micro-teams, giving patients the continuity of care. We are also a teaching and training practice
Job description
Job responsibilities
The purpose of the role is to:
Review all incoming correspondence filing the document and entering pertinent information into the patients electronic 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.
To be responsible for the read coding of relevant information into patients electronic healthcare records on System one clinical system, adhering to the correspondence management policy.
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.
Job description
Job responsibilities
The purpose of the role is to:
Review all incoming correspondence filing the document and entering pertinent information into the patients electronic 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.
To be responsible for the read coding of relevant information into patients electronic healthcare records on System one clinical system, adhering to the correspondence management policy.
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.
Person Specification
Qualifications
Essential
- Essential
- GCSE Mathematics and English (C or above)
- Excellent communication skills (written and oral)
- Strong IT skills
- Clear, polite telephone manner
- Competent in the use of Office and Outlook
- Effective time management (planning and organizing)
- Ability to work as a team member and autonomously
- Good interpersonal skills
- Problem solving and analytical skills
- Ability to follow policy and procedure
- Polite and confident
- Flexible and cooperative
- Motivated
- Forward thinker
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations
- Ability to work under pressure
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
Desirable
- Desirable
- Coder medical experience desirable
- NVQ Level 2 in Health and Social Care
- National Clinical Coding Qualification (NCCQ)
- Emis Trained
- Experience of working in GP Practice
- Experience of administrative duties
- Experience of working in a healthcare setting
- Understanding of clinical coding
Person Specification
Qualifications
Essential
- Essential
- GCSE Mathematics and English (C or above)
- Excellent communication skills (written and oral)
- Strong IT skills
- Clear, polite telephone manner
- Competent in the use of Office and Outlook
- Effective time management (planning and organizing)
- Ability to work as a team member and autonomously
- Good interpersonal skills
- Problem solving and analytical skills
- Ability to follow policy and procedure
- Polite and confident
- Flexible and cooperative
- Motivated
- Forward thinker
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations
- Ability to work under pressure
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
Desirable
- Desirable
- Coder medical experience desirable
- NVQ Level 2 in Health and Social Care
- National Clinical Coding Qualification (NCCQ)
- Emis Trained
- Experience of working in GP Practice
- Experience of administrative duties
- Experience of working in a healthcare setting
- Understanding of clinical coding
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.