HIM Operations Clinical Data Abstractor I

Department: 13533 Enterprise Revenue Cycle - HIM Ops Services and Support Lab Data Abstracting

Major Responsibilities Navigates various electronic health record (EHR) and computer applications to perform job duties to support patient care, care management initiatives, revenue cycle, Health Maintenanceand regulatoryrequirements. 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 electronicallyand ormanually enterappropriate datainto the EHR. Identifies, creates, or releases theappropriate laboratorytests by applying knowledge of medical terminology and laboratory nomenclature. Selects the correct order templates, discretely enters, andvalidateindividual components, comments, footnotes, performing laboratory name and address, collection date and time, units of measure, reference ranges, abbreviations, and symbols. Discretelyabstracts and imports laboratory results and other clinical documentation into the EHR.Recordsnormal and abnormal findings. Ensures laboratory values are accurately entered and flagged to promptly alert patients and cliniciansregardingnormal and abnormal results. Locates or creates theappropriate patient, encounter, and/or order. Correctly paginates and classifies documentation to theappropriate documenttype and description. Ensuresappropriate securitylevels, protection, and destructionofelectronic and physical PHIinformation according toHealth Insurance Portability and Accountability Act (HIPAA). Readilyadapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations. Validates all data points and laboratory codes and uses critical thinking skills toidentifyand investigate questionable information and troubleshoot issues. Escalates issues andreportspatterns of concern to leadershiptimely. Performs quality assurance of scanned documentation to ensure clinical documentation is scanned to the correct patient, encounter, document type, and orderablein a timely manneraccording to Health Information Management policy. Verifies the electronic information against the paper document tovalidateaccuracy, clarity, and legibility Completestimelyerror correction or notificationprocess; including re-resulting ordeletingdocumentation as needed. Ensure secure retention and destruction of electronic and physical PHIin accordance withapplicable 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 entryservicesand other required information. Minimum Job Requirements Education High School Graduate or Equivalent Certification / Registration / License Experience Typically requires 1- 2 years of experience gained through working in aHealth Information Management, Medical Laboratorydepartment or other related healthcare setting. Knowledge / Skills / Abilities 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 whilemaintainingquality and productivity standards. Works collaboratively in a diverse team environment with openness and respect to learn, create andproblem solve. Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success Physical Requirements And Working Conditions This position requires travel, therefore, willbe exposed to weather and road conditions. Operates all equipment necessary to perform the job, performs daily routine maintenance of equipment Exposed to a normal office environment. Reliable Internet Service Preferred Job Requirements Education Experience Knowledge / Skills / Abilities All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities. 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.