HIM Operations Clinical Data Abstractor I

Advocate Health•Oak Brook, IL

2d•$23 - $34

About The Position

The HIM Operations Clinical Data Abstractor I supports patient care, care management initiatives, revenue cycle, Health Maintenance, and regulatory requirements by working in electronic health record (EHR) and other computer applications. The role receives, sorts, prepares, and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures, and analyzes non-interfaced patient laboratory reports for accurate patient identification and compliance with applicable regulations, including Health Maintenance, CAP accreditation, and CLIA. The position uses optical character recognition software and manual data entry to abstract laboratory results and clinical documentation into the EHR. It identifies, creates, or releases appropriate laboratory tests and orders; selects templates; and enters and validates laboratory components and related 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 results are accurately entered and flagged. The role locates or creates the correct patient, encounter, and order; paginates and classifies documentation; and protects and securely retains or destroys electronic and physical protected health information (PHI) in accordance with HIPAA, regulations, and policies. It adapts to evolving tests, parameters, reference ranges, and regulations; validates data and laboratory codes; investigates questionable information; troubleshoots issues; and escalates concerns to leadership. The position 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 the paper document for accuracy, clarity, and legibility. It completes error corrections or notifications, including re-resulting or deleting documentation as needed, and communicates with patient care teams and external performing laboratories by phone, email, fax, Epic In-Basket, and other methods. The position is full-time, scheduled for 40 hours per week, with a minimum of 24 hours per week on first shift, Monday through Friday. It 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 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 such as Epic, Extract LabDE, Solarity, OnBase, Microsoft 365, and legacy archives.
High attention to detail and accuracy while working 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.
Ability to work collaboratively in a diverse team environment with openness and respect to learn, create, and problem solve.
Ability to learn from constructive feedback by leadership or peers and take personal ownership for success.
Ability to travel and be exposed to weather and road conditions.
Ability to operate necessary equipment and perform daily routine equipment maintenance.
Reliable internet service.

Responsibilities

Navigate EHRs 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 correct patient identifiers and compliance with applicable regulations, including Health Maintenance, CAP accreditation, and CLIA.
Use optical character recognition software and manual entry to enter appropriate data into the EHR.
Identify, create, or release appropriate laboratory tests and orders, and select correct order templates.
Enter and validate laboratory components and associated information, including comments, footnotes, performing laboratory information, 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 accurately flag results.
Locate or create the appropriate patient, encounter, and order; paginate and classify documentation to the correct document type and description.
Ensure appropriate security, protection, retention, and destruction of electronic and physical PHI in accordance with HIPAA, 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 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 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 equipment necessary to perform the job and conduct daily routine equipment maintenance.