HIM Operations Clinical Data Abstractor I

Advocate Health and Hospitals Corporation•Milwaukee, WI

22h

About The Position

The HIM Operations Clinical Data Abstractor I supports patient care, care management initiatives, revenue cycle, Health Maintenance, and regulatory requirements by navigating electronic health records and other computer applications. The role receives, sorts, prepares, and scans internal and external clinical documentation into the EHR and abstracts laboratory results and other clinical information, ensuring records are accurate, complete, and properly classified. The position analyzes non-interfaced laboratory reports, enters and validates laboratory data, and ensures normal and abnormal findings are recorded and flagged appropriately. It performs quality assurance on scanned documentation, investigates questionable information, corrects errors, and escalates issues or patterns of concern. The role also communicates with patient care teams and external laboratories to provide education, STAT laboratory data entry services, and other required information. It safeguards physical and electronic protected health information in accordance with applicable regulations and policies. The position is full time, scheduled Sunday through Thursday from 9:00 a.m. to 5:30 p.m., with 40 hours per week. It operates in a normal office environment, requires reliable internet service, and requires travel, exposing the employee to weather and road conditions.

Requirements

High school graduate or equivalent.
Typically 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 new software systems.
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 to learn, create, and solve problems.
Ability to learn from constructive feedback and take personal ownership for success.
Reliable internet service.
Ability to travel for the position and operate necessary equipment.

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 correct patient identifiers and compliance with applicable regulations, including Health Maintenance, CAP accreditation, and CLIA.
Use optical character recognition software and manual entry as needed to enter data into the EHR.
Identify, create, or release appropriate laboratory tests using medical terminology and laboratory nomenclature.
Select order templates and discretely enter and validate laboratory components, comments, footnotes, performing laboratory details, collection date and time, units, 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 laboratory values.
Locate or create the appropriate patient, encounter, and/or order; paginate and classify documentation to the appropriate document type and description.
Ensure appropriate security, protection, retention, and destruction of electronic and physical PHI in accordance with HIPAA, applicable regulations, and policies.
Adapt to changing laboratory tests, parameters, reference ranges, and regulations.
Validate data points and laboratory codes; identify and investigate questionable information, troubleshoot issues, and timely escalate issues and patterns of concern to leadership.
Perform quality assurance of scanned documentation to confirm it is attached to 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 as 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.