Job responsibilities
JOB DESCRIPTION
Clinical Coder
Responsible to: The Practice Manager or Deputy Practice Manager
Main purpose of post: The practice requires pertinent third party information to be read coded in to patients medical records to ensure the electronic record is up to date and accurately maintained
Hours of work: 37.5 hours per week
DUTIES & RESPONSIBILITIES:
The following list of duties should not be regarded as definitive as they may be reviewed from time to time to take account of changing circumstances. Also, tasks and duties may be redistributed amongst the practice team as necessary and cooperation should not be unreasonably withheld.
Review all incoming correspondence and enter, using read codes, pertinent information into the patients electronic medical record in accordance with the coding protocol. This will include data highlighted by clinicians as well as data required to meet contractual obligations.
Highlight clinician action and workflow to appropriate clinician or team as per Workflow Protocol.
Organise the medical record of patients whom you are coding, to harmonise problem titles, group symptom development and assign the appropriate status to medical information.
Recognise own knowledge limits and seek advice from clinical or administrative colleagues as appropriate.
You may be required to assist with note summarising in accordance with the summarising protocol.
To carry out administrative related tasks as delegated by Clinical Lead and Practice Manager.
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 may have access to confidential information relating to patients and their carers, practice 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 & 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 recognizes 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.
Quality:
The post-holder will strive to maintain quality within the practice, and will:
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 and contribute to the overall team working of the Practice putting the needs of the practice first.
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 carers
Recognize peoples needs for alternative methods of communication and respond accordingly.
Dress Code
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 information gathering and audit as appropriate.