Unit Secretary Abstractor

About the role

Candidate will assist physicians and clinic departments by providing clerical and technical support to maintain accurate electronic health data. Work is performed in a team environment following established routines for EHR data entry and communications.

Responsibilities

• Obtain medical records and imaging on patients.
• Perform initial entry of patient data in the EHR.
• Update EHR with incoming patient records from transferring care providers.
• Maintain appropriate records, reconciling information with external and internal sources as necessary.
• Keep work area neat, clean, and safe.
• Cooperate with other personnel to maintain good employee and public relations.
• Inform supervisor or clinic manager of concerns and problems.
• Assist with other EHR assignments as needed.
• Comply with HIPAA regulations.
• Participate in quality measures.
• Accept additional assignments as required.
• Demonstrate a customer-service, high-satisfaction approach when working with providers and patients while entering data into the EHR.
• Abstract records at a minimum rate of 20 charts per day, consistently following departmental standards for:
  • Allergies
  • Medications (as directed by Director of Clinic Operations and Nursing)
  • Medical History
  • Surgical History
  • Family History
  • Immunizations
  • Health Management Screen
  • Diagnostics
  • Quality Information

Requirements

• High School Degree or GED.
• Good interpersonal and communication skills (written and verbal) to effectively interact with physicians, patients, families, and clinic staff.
• 6 months of prior abstracting experience.
• Knowledge of technical medical procedures (preferred).
• Prior medical terminology education (preferred).