Clinical Coder

• Review patient records and supporting clinical documentation to identify information requiring clinical coding.
• Accurately code diagnoses, symptoms, procedures, investigations, treatments and other relevant clinical information.
• Apply appropriate SNOMED CT codes and terminology in accordance with current NHS and primary care standards.
• Identify relevant information contained within:- GP consultations
• hospital discharge summaries
• outpatient letters
• specialist correspondence
• pathology and investigation results
• clinical assessments
• medication-related information
• referral documentation
• other incoming clinical correspondence.
• Ensure coded information accurately reflects the source documentation and does not introduce assumptions or unsupported diagnoses.
• Identify existing codes that may require clarification, amendment or updating.
• Recognise potential duplicate, contradictory or inaccurate coding and escalate appropriately.
• Ensure coding is completed within agreed timescales and in accordance with practice requirements.
• Maintain a high level of attention to detail when reviewing large volumes of clinical information.

• Identify gaps in clinical coding and information capture.
• Support appropriate recording of long-term conditions and significant clinical diagnoses.
• Contribute to data-quality improvement initiatives.
• Identify potential discrepancies between free-text clinical information and coded information.
• Maintain consistency in coding across individual practices wherever appropriate.
• Support the identification of patients who may require further clinical review, where information within the record indicates a potential issue.
• Escalate clinical queries or uncertainties to an appropriate clinician rather than making unsupported clinical judgements.

• Participate in regular quality assurance and audit activity.
• Undertake sample checks of completed work where required.
• Respond positively to feedback and implement agreed improvements.
• Maintain awareness of changes to NHS primary care coding requirements and relevant clinical terminology.
• Support practices with coding-related data-quality projects and audits.
• Maintain appropriate documentation of work completed where required.

• Understand and follow individual practice protocols and workflows.
• Maintain clear communication with practice-based contacts.
• Manage competing priorities across different practices effectively.
• Meet agreed turnaround times and service-level expectations.
• Maintain appropriate boundaries between practices and ensure that patient information is only accessed for legitimate work purposes.
• Work collaboratively with practice managers, GPs, nurses, administrators, data-quality teams and other members of the primary care workforce.

Essential

• Previous experience of clinical coding within primary care, NHS or another relevant healthcare environment.
• Experience working with electronic patient records.
• Experience using clinical terminology and coding systems.
• Experience reviewing clinical correspondence and extracting relevant information.
• Experience working with confidential patient information.
• Experience working independently and managing workload to deadlines.
• Good understanding of clinical coding principles.
• Working knowledge of SNOMED CT.
• Understanding of the importance of accurate and complete GP patient records.
• Understanding of clinical data quality.
• Understanding of confidentiality and information governance.
• Knowledge of UK GDPR and the Data Protection Act 2018.
• Understanding of the importance of not making unsupported clinical assumptions when coding.