Navigates various electronic health record (EHR) and computer applications to perform the following job duties to support patient care, care management initiatives, revenue cycle, regulatory requirements and meaningful use. Receives, collects, sorts, prepares and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures. Sort and measure incoming and remaining scanning to accurately track volumes and turn-around times in the system-wide database. Analyzes non-interfaced patient laboratory reports to ensure patient identifiers and compliance with all applicable regulations including Wisconsin Collaborative for Healthcare Quality (WCHQ) and Clinical Laboratory Improvement Amendments (CLIA) guidelines. 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. For sensitive laboratory information, ensures appropriate security levels and protection of information according to HIPAA rules. 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. 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 to obtain CLIA-compliant reports. 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. Operates all office equipment, performs daily routine maintenance of equipment and reports any equipment malfunction or poor image quality to the appropriate personnel. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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Job Type
Part-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
11-50 employees