HIM Operations Clinical Data Abstractor I

Advocate Health•Milwaukee, WI

3d•$23 - $34

About The Position

The HIM Operations Clinical Data Abstractor I uses electronic health record and computer applications to support patient care, care management initiatives, revenue cycle, Health Maintenance, and regulatory requirements. The role receives, sorts, prepares, and scans clinical documentation into the EHR according to Health Information Management procedures, and analyzes non-interfaced patient laboratory reports for accurate patient identification and compliance with applicable regulations and accreditation requirements. The position uses optical character recognition software and manual data entry to abstract laboratory results and clinical documentation. It identifies, creates, or releases appropriate laboratory tests; selects order templates; and enters and validates laboratory components and details, including comments, footnotes, performing laboratory information, collection date and time, units, reference ranges, abbreviations, and symbols. The abstractor records normal and abnormal findings and ensures values are entered and flagged accurately. The role locates or creates patient, encounter, and order records; classifies and paginates documents; and protects and securely retains or destroys physical and electronic protected health information in accordance with HIPAA, applicable regulations, and policies. It adapts to changing laboratory tests, parameters, reference ranges, and regulations; validates data and codes; investigates questionable information; troubleshoots issues; and escalates concerns to leadership. The abstractor performs quality assurance on scanned documentation, checking that it is associated with the correct patient, encounter, document type, and orderable, and verifying electronic information against source documents for accuracy, clarity, and legibility. The role completes error corrections or notifications, including re-resulting or deleting documentation when needed, and communicates with patient care teams and external laboratories through phone, email, fax, Epic In-Basket, and other methods. The position is part-time, with a Monday–Friday zero-assignment schedule and a minimum of 24 hours per week. It requires travel and exposure to weather and road conditions, work in a normal office environment, reliable internet service, and operation and routine maintenance of necessary equipment.

Requirements

High school graduate or equivalent.
Typically requires 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 collaborate in a diverse team environment with openness and respect to learn, create, and problem solve.
Ability to learn from constructive feedback from leadership or peers and take personal ownership for success.
Ability to travel and be exposed to weather and road conditions.
Reliable internet service.
Ability to operate necessary equipment and perform routine equipment maintenance.

Responsibilities

Navigate EHR and other computer applications to support patient care, care management, 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 patient identifiers and compliance with applicable regulations and accreditation requirements.
Use optical character recognition software and manual entry to enter data into the EHR.
Identify, create, or release appropriate laboratory tests and select correct order templates.
Enter and validate laboratory components and details, including comments, footnotes, performing laboratory name and address, collection date and time, units of measure, reference ranges, abbreviations, and symbols.
Abstract and import laboratory results and other clinical documentation into the EHR; record normal and abnormal findings and ensure results are accurately entered and flagged.
Locate or create the appropriate patient, encounter, and/or order; paginate and classify documentation to the appropriate type and description.
Protect, retain, and destroy electronic and physical PHI according to HIPAA, applicable regulations, and policies.
Adapt to changes in 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 confirm 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 when necessary.
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 equipment necessary to perform the job and perform routine daily equipment maintenance.