HIM Operations Clinical Data Abstractor I

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 validates 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.