HIM Operations Clinical Data Abstractor I

Advocate Health•Milwaukee, WI

3d•$23 - $34

About The Position

The Clinical Data Abstractor I supports patient care, care management initiatives, revenue cycle, Health Maintenance, and regulatory requirements by using electronic health records and other computer applications. The role receives, sorts, prepares, and scans clinical documentation into the EHR, and abstracts non-interfaced laboratory reports and other clinical information into the record. The position verifies patient identifiers and regulatory compliance; identifies or creates appropriate patients, encounters, orders, and laboratory tests; and enters and validates laboratory data, including components, comments, performing laboratory details, collection information, units, reference ranges, and normal or abnormal findings. It also classifies and paginates documents, performs quality checks against source documents, corrects errors, and protects and securely retains or destroys protected health information in accordance with applicable policies and regulations. The role adapts to changing tests, parameters, reference ranges, and regulations; investigates questionable information and escalates concerns. It communicates with patient care teams and external laboratories by phone, email, fax, Epic In-Basket, and other methods, including to provide education and STAT laboratory data entry services. The position is full time, 40 hours per week, Monday through Friday, 8:30 a.m. to 5:00 p.m., with a listed pay range of $22.90 to $34.35.

Requirements

High school graduate or equivalent.
Typically 1–2 years of experience gained in Health Information Management, a medical laboratory department, or another related health care setting.
Proficient computer and keyboarding skills, with the ability to learn software systems such as Epic, Extract LabDE, Solarity, OnBase, Microsoft 365, and legacy archives.
High attention to detail and accuracy while managing 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.
Ability to work collaboratively in a diverse team environment with openness and respect.
Ability to learn from constructive feedback and take personal ownership for success.
Ability to travel, with exposure to weather and road conditions.

Responsibilities

Use EHR and computer applications to support patient care, care management initiatives, revenue cycle, Health Maintenance, and regulatory requirements.
Receive, sort, prepare, and scan internal and external clinical documentation into the EHR according to HIM procedures.
Analyze non-interfaced patient laboratory reports for accurate patient identifiers and compliance with applicable requirements, including Health Maintenance, CAP accreditation, and CLIA.
Use optical character recognition software and manual entry to enter appropriate information into the EHR.
Identify, create, or release appropriate laboratory tests, select order templates, and enter and validate laboratory components and associated details.
Abstract and import laboratory results and other clinical documentation into the EHR; record normal and abnormal findings and ensure values are accurately entered and appropriately flagged.
Locate or create the appropriate patient, encounter, and order; paginate and classify documentation to the correct document type and description.
Protect and securely retain or destroy electronic and physical PHI in accordance with HIPAA, applicable regulations, and policies.
Adapt to evolving laboratory tests, parameters, reference ranges, and regulations; validate data and codes, investigate questionable information, troubleshoot issues, and escalate concerns or patterns to leadership.
Perform quality assurance of scanned documentation to verify the correct patient, encounter, document type, and orderable, and compare electronic information with the source document for accuracy, clarity, and legibility.
Complete timely error corrections or notifications, including re-resulting or deleting documentation as needed.
Communicate with patient care teams and external performing laboratories through phone, email, fax, Epic In-Basket, and other methods to provide education, STAT laboratory data entry, and other required information.
Operate necessary equipment and perform its daily routine maintenance.