HIM Operations Clinical Data Abstractor I

Advocate Health and Hospitals Corporation • Milwaukee, WI

2d

About The Position

The HIM Operations Clinical Data Abstractor I uses electronic health record (EHR) and computer applications to support patient care, care management, revenue cycle, Health Maintenance, and regulatory requirements. The role receives, sorts, prepares, scans, analyzes, and abstracts clinical documentation and non-interfaced laboratory reports into the EHR, ensuring accurate patient, encounter, order, and document classification. It applies medical terminology and laboratory nomenclature to create or release appropriate laboratory tests and enter and validate laboratory result details, including components, comments, performing laboratory information, collection dates and times, units, reference ranges, abbreviations, and symbols. The role records normal and abnormal findings and flags results appropriately to alert patients and clinicians.

The position performs quality assurance by checking scanned and entered information against source documents, correcting errors or notifying others as needed, and ensuring timely, accurate documentation. It protects and securely retains or destroys physical and electronic protected health information (PHI) in accordance with HIPAA and applicable policies. The abstractor adapts to evolving tests, parameters, reference ranges, and regulations; investigates questionable information, troubleshoots issues, and escalates concerns. The role also communicates with patient care teams and external performing laboratories through phone, email, fax, Epic In-Basket, and other methods, including to provide education and STAT laboratory data entry services.

This is a full-time, benefits-eligible position, scheduled Monday through Friday from 8:30 a.m. to 5:00 p.m., with 40 hours per week. The position operates in a normal office environment, requires reliable internet service, and requires travel, which may involve exposure to weather and road conditions. The employee operates and performs routine daily maintenance on necessary equipment.

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 and ability to learn software systems 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 collaborate in a diverse team environment with openness and respect, and to learn, create, and solve problems collaboratively.
• Ability to learn from constructive feedback from leadership or peers and take personal ownership for success.
• Ability to travel and reliable internet service.

Responsibilities

• Navigate EHR and 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 Health Maintenance, CAP, and CLIA requirements.
• Use optical character recognition software and manual entry to place appropriate data 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 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, recording normal and abnormal findings and accurately flagging laboratory values.
• Locate or create the appropriate patient, encounter, and/or order; paginate and classify documentation under the correct document type and description.
• Protect PHI through appropriate security, retention, and destruction practices for electronic and physical records, 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 in a timely manner.
• Verify electronic information against paper documents for accuracy, clarity, and legibility.
• Complete timely error correction or notification processes, 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 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 and other financial wellness programs.
• Educational Assistance Program.
• Competitive compensation, premium pay for eligible positions, incentive pay for select positions, and opportunity for annual performance-based increases.
• Career development programs and well-being programs.

What This Job Offers

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