HIM Operations Clinical Data Abstractor I

Advocate Health • Milwaukee, WI

2d • $23 - $34

About The Position

The HIM Operations Clinical Data Abstractor I uses electronic health record (EHR) and other computer applications to support patient care, care management, revenue cycle, Health Maintenance, and regulatory requirements. The role receives, sorts, prepares, and scans clinical documentation into the EHR in accordance with Health Information Management (HIM) procedures. It analyzes non-interfaced patient laboratory reports for accurate patient identification and regulatory compliance, and uses optical character recognition software or manual entry to add data to the EHR.

The position identifies, creates, or releases laboratory tests and enters and validates laboratory report components, including comments, performing laboratory information, collection dates and times, units, reference ranges, and results. It locates or creates the appropriate patient, encounter, and order; classifies and paginates documents; and protects and securely retains or destroys protected health information (PHI). The abstractor adapts to changing tests and regulations, validates data and codes, investigates questionable information, and escalates concerns.

The role also performs quality assurance on scanned documents, corrects or reports errors, and communicates with patient care teams and external laboratories through phone, email, fax, Epic In-Basket, and other methods. This is a full-time, 40-hour-per-week position on a day schedule from 8:00 a.m. to 4:30 p.m. Central Time, with every other weekend required. The position requires travel and exposure to weather and road conditions, operation and routine maintenance of necessary equipment, a normal office environment, and reliable internet service.

Requirements

• High school graduate or equivalent.
• Typically requires 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 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.
• Ability to learn from constructive feedback and take personal ownership for success.
• Ability to travel and work in a normal office environment; reliable internet service is required.
• Ability to operate necessary equipment and perform daily routine maintenance.

Responsibilities

• Navigate EHR and computer applications to support patient care, care management, revenue cycle, Health Maintenance, and regulatory requirements.
• Receive, sort, prepare, and scan clinical documentation into the EHR according to HIM procedures.
• Analyze non-interfaced laboratory reports for patient identification and compliance with applicable regulations, including Health Maintenance, CAP accreditation, and CLIA.
• Use optical character recognition software or manual entry to enter data into the EHR.
• Identify, create, or release appropriate laboratory tests and enter and validate test components, laboratory details, and results.
• Abstract and import laboratory results and clinical documentation into the EHR; record normal and abnormal findings and accurately flag laboratory values.
• Locate or create the appropriate patient, encounter, and order; paginate and classify documentation to the correct document type and description.
• Protect, retain, and securely destroy electronic and physical PHI in accordance with HIPAA, applicable regulations, and policies.
• Adapt to changing laboratory tests, parameters, reference ranges, and regulations; validate data points and codes, investigate questionable information, troubleshoot issues, and escalate concerns or patterns to leadership.
• Perform quality assurance on scanned documentation to ensure it is associated with the correct patient, encounter, document type, and orderable, and verify electronic information against paper documents 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 by 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.

Benefits

• 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
• Financial wellness programs
• Educational Assistance Program
• Competitive compensation, with possible premium pay, select-position incentive pay, and annual performance-based increases

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED