HIM Operations Clinical Data Abstractor I

Advocate Health•Milwaukee, WI

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 records and other computer applications. The position receives, sorts, prepares, scans, analyzes, and abstracts clinical documentation and non-interfaced laboratory reports into the EHR. It ensures records and laboratory data are accurate, appropriately classified, and handled in compliance with applicable regulations and Health Information Management procedures. The role uses optical character recognition and manual data entry to capture laboratory results and associated details, including test components, comments, performing laboratory information, collection dates and times, units, reference ranges, and abnormal findings. The abstractor verifies patient, encounter, document, and order information; performs quality assurance; investigates questionable data; corrects errors; and escalates issues or patterns of concern. The position communicates with patient care teams and external laboratories through phone, email, fax, Epic In-Basket, and other methods. This is a full-time position scheduled Sunday through Thursday, 9:00 a.m. to 5:30 p.m., for 40 hours per week. The work is performed in a normal office environment and requires reliable internet service. The position requires travel and exposure to weather and road conditions, as well as operation and routine maintenance of 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, 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 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 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.
Ability to operate necessary equipment and perform daily routine maintenance.
Reliable internet service.

Responsibilities

Navigate EHR and computer applications to support patient care, care management initiatives, 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 data entry to enter 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 test components and related details.
Abstract and import laboratory results and other clinical documentation into the EHR, record normal and abnormal findings, and ensure values are accurately entered and flagged.
Locate or create the appropriate patient, encounter, and/or order; paginate and classify documentation using the appropriate document type and description.
Maintain appropriate security, protection, retention, and destruction of electronic and physical PHI in accordance with HIPAA, other applicable 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 confirm it is associated with the correct patient, encounter, document type, and orderable; compare electronic information with the source paper document 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 necessary equipment and perform its daily routine maintenance.