HIM Abstractor
About The Position
Under the direction of the HIM Manager, and in conjunction with the CIO, the HIM Abstractor performs operational tasks supporting the agency and its Health Information Management (HIM) Department. The role supports HIM activities involving medical record and chart analysis, data abstraction, and targeted clinical quality measurement efforts. The position reviews assigned medical records and abstracts clinical data for quality measurement reporting. It also contributes to HIM training, documentation of gaps identified in record reviews, process improvement, and communication of significant findings to relevant teams. The role serves patients of all ages.
Requirements
- Proficiency with databases and ability to perform 80% of work activities on a computer.
- Ability to work in a team environment and make sound decisions.
- Excellent interpersonal skills and ability to work effectively in a team environment.
- Good written and verbal communication skills.
- Demonstrated command of medical terminology, medical record documentation, and clinical processes.
- Strong time-management skills.
Nice To Haves
- Electronic Health Record (EHR) system experience is strongly recommended.
- Knowledge of SNOMED CT, ICD-9/10-CM, CPT, and HCPCS coding conventions is a plus.
- RHIA or RHIT certification preferred.
- At least 2 years of experience in Medical Records or HIM operations is highly desired.
- Bilingual English/Spanish skills are desirable.
- Experience managing, planning, organizing, and prioritizing is preferred.
Responsibilities
- Assist in designing and implementing HIM training modules covering document management, PHI correspondence, record/chart analysis, data abstraction, targeted QA/QC activities, and archive management.
- Communicate additional strategies for pursuing medical records to other team members when needed.
- Communicate significant findings, including potential risk-management issues, promptly to Clinical Quality or Utilization.
- Integrate data collected from electronic and paper sources.
- Maintain written documentation of gaps in medical record documentation for educating practice locations about improvement opportunities.
- Review assigned medical records and abstract clinical data elements for clinical quality measurement reporting, including laboratory results, hypertension verification and recent blood pressure readings, and prenatal and postpartum care services.
- Work with the HIM management team to identify EHR and HIM workflow issues and recommend resolutions or modifications, particularly concerning the paper/electronic interface and daily workflow.
- Produce accurate and precise work.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
