Clinical coder/Medical Summariser

• Review new patient medical records and summarise relevant past medical history.
• Read and process hospital letters, discharge summaries, outpatient correspondence, investigation results and other clinical documentation.
• Identify and accurately record diagnoses, procedures, medications, allergies, significant medical history and other relevant clinical information.
• Apply appropriate clinical codes in accordance with practice procedures and established coding standards.
• Ensure patient records are maintained accurately and consistently.
• Identify missing, unclear or potentially significant information and refer appropriately to the relevant clinician or practice team member.
• Process incoming clinical correspondence within agreed timescales.
• Maintain strict patient confidentiality and comply with GDPR, NHS information governance and practice policies.
• Follow practice procedures relating to safeguarding, data protection, information security and patient safety.
• Liaise with GPs, nurses, administrative staff and other members of the multidisciplinary team when clarification or further action is required.
• Maintain a high level of accuracy while working to agreed deadlines and workload requirements.
• Undertake any other appropriate duties relevant to the role and level of responsibility.

Essential

• GCSEs or equivalent, including English and Mathematics.
• Qualification or training in medical terminology, medical administration or clinical coding.
• Evidence of good IT and administrative skills.
• Ability to accurately interpret and record information from medical documentation.

Desirable

• NVQ/QCF Level 2 or 3 in Business Administration, Health and Social Care, or a related subject.
• Previous NHS or primary care-related training.
• Knowledge or training in SNOMED CT, Read coding, EMIS or System One.

Essential

• Essential:
• Good understanding of medical terminology.
• Excellent attention to detail and accuracy.
• Good written and verbal communication skills.
• Strong organisational and time-management skills.
• Ability to work independently and manage workload effectively.
• Good IT skills and confidence using electronic clinical records.
• Understanding of confidentiality and the importance of protecting patient information.
• Ability to work as part of a multidisciplinary team.

Desirable

• Previous experience in an NHS, GP practice or other healthcare environment.
• Experience of reviewing and summarising medical records.
• Knowledge of clinical coding systems, such as Read Codes or SNOMED CT.
• Previous experience using primary care clinical systems such as EMIS or System One.