HIM Operations Clinical Data Abstractor I

Advocate Health and Hospitals Corporation•Milwaukee, WI

1d•Remote

About The Position

This full-time position is responsible for abstracting clinical data within the Health Information Management (HIM) department. The role involves navigating electronic health records (EHR) and other computer applications to support patient care, revenue cycle, and regulatory requirements. Key duties include preparing and scanning clinical documentation, analyzing laboratory reports for accuracy and compliance, and entering data into the EHR using optical character recognition software. The abstractor will identify and enter laboratory tests, validate components, and abstract laboratory results, ensuring accurate flagging of normal and abnormal findings. The position also requires ensuring proper patient and encounter information is correctly paginated and classified, maintaining the security and protection of Protected Health Information (PHI) in accordance with HIPAA. Adaptability to evolving laboratory tests and regulations, critical thinking for data validation and issue troubleshooting, and timely escalation of concerns are essential. Quality assurance of scanned documentation, verification of electronic information against paper documents, and timely error correction are also key responsibilities. Communication with internal teams and external laboratories via various methods is required to provide education and data entry services.

Requirements

Typically requires 1-2 years of experience gained through working in a Health Information Management, Medical Laboratory department or other related health care setting.
Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, Extract LabDE, Solarity, OnBase, Microsoft 365 and legacy archives.
High attention to detail and accuracy 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.
Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve.
Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success.
High School Graduate or Equivalent.
Reliable Internet Service.

Nice To Haves

HIM and or Laboratory Experience desired

Responsibilities

Navigates various electronic health record (EHR) and computer applications to perform job duties to support patient care, care management initiatives, revenue cycle, Health Maintenance and regulatory requirements.
Receives, sorts, prepares, and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures.
Analyzes non-interfaced patient laboratory reports to ensure patient identifiers and compliance with all applicable regulations including Health Maintenance, College of American Pathologist (CAP) Accreditation, and Clinical Laboratory Improvement Amendments (CLIA).
Utilizes optical character recognition software to electronically and or manually enter appropriate data into the EHR.
Identifies, creates, or releases the appropriate laboratory tests by applying knowledge of medical terminology and laboratory nomenclature.
Selects the correct order templates, discretely enters, and validate individual components, comments, footnotes, performing laboratory name and address, collection date and time, units of measure, reference ranges, abbreviations, and symbols.
Discretely abstracts and imports laboratory results and other clinical documentation into the EHR.
Records normal and abnormal findings.
Ensures laboratory values are accurately entered and flagged to promptly alert patients and clinicians regarding normal and abnormal results.
Locates or creates the appropriate patient, encounter, and/or order.
Correctly paginates and classifies documentation to the appropriate document type and description.
Ensures appropriate security levels, protection, and destruction of electronic and physical PHI information according to Health Insurance Portability and Accountability Act (HIPAA).
Readily adapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations.
Validates all data points and laboratory codes and uses critical thinking skills to identify and investigate questionable information and troubleshoot issues.
Escalates issues and reports patterns of concern to leadership timely.
Performs quality assurance of scanned documentation to ensure clinical documentation is scanned to the correct patient, encounter, document type, and orderable in a timely manner according to Health Information Management policy.
Verifies the electronic information against the paper document to validate accuracy, clarity, and legibility.
Completes timely error correction or notification process; including re-resulting or deleting documentation as needed.
Ensure secure retention and destruction of electronic and physical PHI in accordance with applicable regulations and policies.
Communicates with patient care and external performing laboratories via phone, email, fax, Epic In-Basket, and other methods to provide education, STAT laboratory data entry services and other required information.

Benefits

Comprehensive suite of Total Rewards: benefits and well-being programs
Competitive compensation
Generous retirement offerings
Programs that invest in your career development
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program