HIM Operations Clinical Data Abstractor I

Advocate Health and Hospitals Corporation•Milwaukee, WI

About The Position

The HIM Operations Clinical Data Abstractor I uses electronic health record and other computer applications to support patient care, care management, revenue cycle, Health Maintenance, and regulatory requirements. The role receives, sorts, prepares, scans, abstracts, and imports clinical documentation and non-interfaced laboratory reports into the EHR. It validates patient identifiers, laboratory data, codes, and documentation details, and accurately records and flags normal and abnormal results. The position also performs quality assurance, corrects errors, protects and securely retains or destroys protected health information, and communicates with patient care teams and external laboratories to provide education, STAT laboratory data entry services, and other information. The position works third shift, Monday through Friday, for 40 hours per week, with flexibility within the third shift. It is exposed to a normal office environment, requires reliable internet service, and involves travel with exposure to weather and road conditions. The incumbent operates and performs routine maintenance on necessary equipment. The job description notes that duties may be modified to reasonably accommodate individuals with disabilities and that other related duties may be assigned.

Requirements

High school graduate or equivalent.
Typically 1–2 years of experience 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 handling 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 collaborate in a diverse team environment with openness and respect to learn, create, and solve problems.
Ability to learn from constructive feedback from leadership or peers and take personal ownership for success.
Reliable internet service.
Ability to travel and be exposed to weather and road conditions.
Ability to operate equipment necessary for the job and perform routine daily equipment maintenance.

Responsibilities

Navigate EHR and other 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 correct patient identifiers and compliance with applicable regulations, including Health Maintenance, CAP accreditation, and CLIA.
Use optical character recognition software and manual data entry to enter appropriate information into the EHR.
Identify, create, or release appropriate laboratory tests using medical terminology and laboratory nomenclature.
Select order templates and enter and validate laboratory components, comments, footnotes, performing laboratory details, collection dates and times, units, reference ranges, abbreviations, and symbols.
Abstract and import laboratory results and other clinical documentation into the EHR, recording normal and abnormal findings and accurately flagging results.
Locate or create the appropriate patient, encounter, and/or order; paginate and classify documentation under the correct document type and description.
Maintain appropriate security, protection, retention, and destruction of electronic and physical PHI in accordance with HIPAA, regulations, and policies.
Adapt to evolving laboratory tests, parameters, reference ranges, and regulations; validate data points and laboratory codes; investigate questionable information and troubleshoot issues.
Escalate issues and report patterns of concern to leadership in a timely manner.
Perform quality assurance on scanned documentation to ensure it is associated with the correct patient, encounter, document type, and orderable, and meets HIM policy and timeliness requirements.
Verify electronic information against paper documents for accuracy, clarity, and legibility; complete timely error corrections or notifications, including re-resulting or deleting documentation when needed.
Communicate with patient care teams and external performing laboratories by phone, email, fax, Epic In-Basket, and other methods to provide education, STAT laboratory data entry services, and other required information.
Operate necessary equipment and perform its daily routine maintenance.

Benefits

Comprehensive benefits and well-being programs.
Competitive compensation and premium pay, including shift and on-call pay where applicable.
Incentive pay for select positions and opportunity for annual performance-based increases.
Paid Time Off programs.
Medical, dental, vision, life, and short- and long-term disability benefits.
Flexible Spending Accounts for eligible health care and dependent care expenses.
Adoption assistance and paid parental leave.
Defined contribution retirement plans with employer match and other financial wellness programs.
Educational Assistance Program.
Career development programs.