HIM Operations Clinical Data Abstractor I
About The Position
This full-time position is responsible for abstracting clinical data within the Health Information Management (HIM) department. The role involves navigating electronic health records (EHR) and various computer applications to support patient care, revenue cycle, and regulatory requirements. Key duties include preparing, scanning, and analyzing clinical documentation, particularly non-interfaced patient laboratory reports, to ensure accuracy and compliance with regulations such as Health Maintenance, CAP Accreditation, and CLIA. The abstractor will utilize optical character recognition software and possess knowledge of medical terminology to enter and validate laboratory data into the EHR, ensuring correct identification of tests, parameters, and results. This role requires a high level of attention to detail, critical thinking for data validation and issue resolution, and effective communication with internal and external stakeholders. The position also involves performing quality assurance on scanned documents and ensuring the secure handling of Protected Health Information (PHI) in accordance with HIPAA.
Requirements
- 1-2 years of experience in Health Information Management, a Medical Laboratory department, or other related healthcare setting.
- Proficient computer and keyboarding skills.
- 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.
- High School Graduate or Equivalent.
- Reliable Internet Service.
Nice To Haves
- HIM and or Laboratory Experience desired.
- Experience with Epic, Extract LabDE, Solarity, OnBase, Microsoft 365 and legacy archives.
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 all applicable regulations including Health Maintenance, College of American Pathologist (CAP) Accreditation, and Clinical Laboratory Improvement Amendments (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 validate individual components, comments, footnotes, performing laboratory name and address, 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.
- Ensures laboratory values are accurately entered and flagged to promptly alert patients and clinicians regarding normal and abnormal results.
- 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 information according to Health Insurance Portability and Accountability Act (HIPAA).
- Readily adapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations.
- Validates all data points and laboratory codes and uses critical thinking skills to identify and investigate questionable information and troubleshoot issues.
- Escalates issues and reports patterns of concern to leadership timely.
- Performs quality assurance of scanned documentation to ensure clinical documentation is scanned to the correct patient, encounter, document type, and orderable in a timely manner according to Health Information Management policy.
- Verifies the electronic information against the paper document to validate accuracy, clarity, and legibility
- Completes timely error correction or notification process; including re-resulting or deleting documentation as needed.
- Ensure secure retention and destruction of electronic and physical PHI in accordance with applicable regulations and policies
- 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.
Benefits
- Comprehensive suite of Total Rewards: benefits and well-being programs
- Competitive compensation
- Generous retirement offerings
- Programs that invest in your career development
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
