HIM Operations Clinical Lab Data Abstractor

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 datainto 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, andvalidateindividual 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 cliniciansregardingnormal 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 destructionofelectronic 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 toidentifyand investigate questionable information and troubleshoot issues. Escalates issues andreportspatterns 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 orderablein a timely manner according to Health Information Management policy. Verifies the electronic information against the paper document tovalidateaccuracy, clarity, and legibility

Completestimelyerror correction or notification process;including re-resulting ordeletingdocumentation as needed. Ensure secure retention and destruction of electronic and physical PHIin accordance with applicable 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.

High School Graduateor Equivalent

Typically requires1-2years of experiencegainedthroughworking in aHealth Information Management,Medical Laboratory department or other related healthcare setting.

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 and problem solve.

Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success

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

Allresponsibilitiesand requirements are subject to possible modificationtoreasonably 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…