Medical Coder

Description:

The Medical/Clinical Coder is responsible for reviewing, summarising, and accurately coding incoming clinical documentation to ensure that only items requiring GP attention are escalated to Team Lead, while the remaining documents are appropriately recorded in the patient's electronic medical record. This role ensures accurate data capture to support safe clinical care, meet contractual obligations, and maintain comprehensive patient records. The role requires attention to detail, familiarity with clinical terminology, and the ability to work independently or as part of a team. 

 
2. Key Responsibilities / Duties

Training and Probation
· All newly hired Medical/Clinical Coder will undergo a structured 1-month training program, including:
o Introduction to EMIS, SystmOne, Docman
o Clinical document handling and coding protocols
o Quality standards, escalation process, and performance expectations
· After successful completion of training, the candidate will enter a 3-month probationary period in the role of Junior Medical/Clinical Coder, during which:
o Expected to process a minimum of 50 letters per day within their assigned practice.
o If the assigned practice does not have sufficient workload, it is the responsibility of the team member to proactively inform the Team Lead and Operations Manager by the start of the day or as soon as the shortfall is identified.
o Daily performance will be monitored against KPIs
o Accuracy and turnaround expectations will be evaluated
o Regular feedback and mentoring will be provided by the Team Lead
o Upon satisfactory performance, the role will be confirmed as Medical/Clinical Coder 

· Review and analyze clinical documents to extract and code relevant information.
· Accurately assign SNOMED and other industry-standard codes in alignment with current guidance.
· Expected to process a minimum of 65 letters per day within their assigned practice.
· If the assigned practice does not have sufficient workload, it is the responsibility of the team member to proactively inform the Team Lead and Operations Manager by the start of the day or as soon as the shortfall is identified.
· Identify and flag missing or unclear information in patient records.
· File documents into EMIS Web, Docman, or SystmOne in line with the practice’s Clinical Coding Protocol.
· Apply awareness of QOF (Quality and Outcomes Framework) targets, PCN DES (Primary Care Network Directed Enhanced Service), and other clinical targets when coding.
· Escalate documents appropriately for clinical review where needed.
· Contribute to internal audits and assist in quality assurance reviews.
· Support the Team Lead in providing regular status reports and performance summaries.
· Maintain personal productivity in line with agreed daily/weekly targets.
· Communicate proactively with team members to ensure smooth workflow and avoid duplication.
· Participate in team meetings, training sessions, and feedback reviews.
· Undertake reasonable additional tasks as requested by the Team Lead or Management Team.
· Provide cover for absent colleagues when required.
· Maintain full compliance with GDPR and the organization's confidentiality policies.
· Handle all patient and practice data sensitively and securely.
· Demonstrate respect for colleagues and patients from all backgrounds.
· Uphold equality, diversity, and inclusion principles at all times.
· Participate in SEAs (Significant Event Analyses) and continuous improvement projects.
· Work efficiently to ensure accuracy and performance benchmarks are met.
· Take responsibility for ongoing learning and professional development.
· Participate in mandatory and role-specific training programs.

3. Authorities

· Authorized to access EMIS Web, SystmOne, Docman, and other relevant systems for the purpose of document processing and clinical coding.
· Authority to review, code, file, and process all incoming clinical documentation as per standard protocol.
· Authority to escalate documents to Team Leads when a document requires clinical input or further action.
· Direct communication with coding Team Members, Team Lead(s), Operations Manager and HR.
· Authority to raise discrepancies or quality concerns to the Team Lead for resolution or audit.
· Authorized to participate in internal audit processes and provide feedback on improvements.
· Authority to access internal and external training platforms and participate in coding upskilling programs.
· May propose amendments or improvements to the coding protocol to the Team Lead based on observed gaps or efficiency opportunities.

4. Qualifications

· Diploma / Bachelor’s degree in Management, Health Information Management, Medical Records, Life Sciences, Nursing, or a related healthcare field. 

5. Experience

· Minimum 1 years of experience in a same field or relevant field.
· Good Understanding in clinical coding standards (e.g., ICD-10, NHS coding standards, or equivalent international standards).