Clinical CoderNHS

Job summary

The Remote Clinical Coder will provide high-quality, accurate and timely clinical coding support to multiple GP surgeries across England.

The role will involve reviewing clinical records, consultations, correspondence, investigation results, hospital documentation and other relevant patient information and ensuring that appropriate clinical information is accurately recorded within the GP clinical system.

Main duties of the job

The postholder will support practices to maintain high-quality, complete and clinically meaningful patient records, ensuring that relevant diagnoses, procedures, investigations, conditions and other coded information are captured appropriately.

Working remotely across a number of practices, the Clinical Coder will need to adapt to different practice workflows, clinical systems and local processes while maintaining consistent standards of accuracy, confidentiality and data quality.

The role will contribute directly to the quality of patient records, clinical safety, practice performance, population health management, reporting and the effective use of primary care data.

Job description

Clinical Coding

• 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.

Record Management and Data Quality

• Support practices to maintain accurate, complete and up-to-date patient records.
• 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.

Quality and Performance

• Work to agreed coding accuracy and productivity standards.
• 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.

Working Across Multiple Practices

• Provide coding services to multiple GP practices and adapt to different practice requirements.
• 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.

About us

We are an established primary care provider delivering high-quality NHS healthcare across a growing network of GP practices in England.

Our approach is built around combining the strengths of local practices with the benefits of operating at scale. Each practice retains its local identity and connection with its patients and communities, while benefiting from centralised support, shared expertise, robust governance and investment in people, technology and services.

We are committed to providing accessible, safe and effective primary care while creating an environment in which our clinical and non-clinical teams can thrive.