HIM Operations Clinical Data Abstractor I

This position supports patient care, care management, revenue cycle, Health Maintenance and regulatory requirements through electronic health record and laboratory data abstracting work within Health Information Management (HIM) Operations Services and Support. Zero Assigned Position requiring a minimum of 24 hours per week on the First Shift, M-F.

Responsibilities

Navigates various electronic health record (EHR) and computer applications to perform job duties to support patient care, care management initiatives, revenue cycle, Health Maintenance and regulatory requirements; Receives, sorts, prepares, and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures; Analyzes non-interfaced patient laboratory reports to ensure patient identifiers and compliance with applicable regulations including Health Maintenance, CAP Accreditation, and CLIA; Utilizes optical character recognition software to electronically and or manually enter appropriate data into the EHR; Identifies, creates, or releases the appropriate laboratory tests by applying knowledge of medical terminology and laboratory nomenclature; Selects the correct order templates, discretely enters, and validates individual laboratory components, comments, footnotes, collection date and time, units of measure, reference ranges, abbreviations, and symbols; Discretely abstracts and imports laboratory results and other clinical documentation into the EHR; Records normal and abnormal findings and ensures laboratory values are accurately entered and flagged to promptly alert patients and clinicians; Locates or creates the appropriate patient, encounter, and/or order; Correctly paginates and classifies documentation to the appropriate document type and description; Ensures appropriate security levels, protection, and destruction of electronic and physical PHI according to HIPAA; Readily adapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations; Validates all data points and laboratory codes and troubleshoots questionable information; Escalates issues and reports patterns of concern to leadership timely; Performs quality assurance of scanned documentation to ensure correct patient, encounter, document type, and orderable, verifying electronic information against paper documents; Completes timely error correction or notification process, including re-resulting or deleting documentation as needed; Ensures secure retention and destruction of electronic and physical PHI; Communicates with patient care and external performing laboratories via phone, email, fax, Epic In-Basket, and other methods to provide education, STAT laboratory data entry services and other required information

Requirements

High School Graduate or Equivalent; Typically requires 1-2 years of experience gained through working in a Health Information Management, Medical Laboratory department or other related health care setting; Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, Extract LabDE, Solarity, OnBase, Microsoft 365 and legacy archives; High attention to detail and accuracy with frequent interruptions; Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints; Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards; Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve; Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success; Reliable Internet Service; Requires travel, exposure to weather and road conditions; Operates all equipment necessary to perform the job and performs daily routine maintenance of equipment

Benefits

Compensation: base compensation within the listed pay range; premium pay such as shift and on-call pay; incentive pay for select positions; opportunity for annual increases based on performance; Paid Time Off programs; Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability; Flexible Spending Accounts for eligible health care and dependent care expenses; Family benefits such as adoption assistance and paid parental leave; Defined contribution retirement plans with employer match and other financial wellness programs; Educational Assistance Program