HIM Data Abstractor

Job Summary

The Health Information Management (HIM) Data Abstractor is responsible for reviewing, analyzing, and abstracting clinical and demographic information from paper medical records, external healthcare records, health information exchanges, Continuity of Care Documents (CCDs), and other electronic health records into the Northfield Hospital + Clinics electronic medical record (EMR). This position supports the integrity, completeness, and accessibility of the medical record to ensure accurate patient information is available to support ongoing patient care, regulatory compliance, quality initiatives, and organizational operations.

The HIM Data Abstractor applies knowledge of medical terminology, anatomy and physiology, clinical documentation, healthcare workflows, and health information management principles to accurately identify, organize, and enter relevant patient information into the designated sections of the EMR while maintaining the confidentiality and security of protected health information.

The Health Information Management (HIM) Data Abstractor is responsible for reviewing, analyzing, and abstracting clinical and demographic information from paper medical records, external healthcare records, health information exchanges, Continuity of Care Documents (CCDs), and other electronic health records into the Northfield Hospital + Clinics electronic medical record (EMR). This position supports the integrity, completeness, and accessibility of the medical record to ensure accurate patient information is available to support ongoing patient care, regulatory compliance, quality initiatives, and organizational operations.

The HIM Data Abstractor applies knowledge of medical terminology, anatomy and physiology, clinical documentation, healthcare workflows, and health information management principles to accurately identify, organize, and enter relevant patient information into the designated sections of the EMR while maintaining the confidentiality and security of protected health information.

We are committed to providing wage ranges for all open positions. Please note that the specific compensation for this role will be determined based on experience, education and internal equity considerations. The hourly wage range for this position is $20.27-$28.61. This range reflects the base salary for this position.

• Reviews, analyzes, and abstracts pertinent patient information from paper records, external records, Continuity of Care Documents (CCDs), health information exchanges, and electronic medical records into the NH+C electronic medical record.
• Ensures abstracted information is accurate, complete, appropriately categorized, and entered into the correct location within the electronic health record.
• Identifies, investigates, and resolves inconsistencies, discrepancies, duplicate information, and incomplete documentation while maintaining the integrity of the medical record.
• Assists with the review, validation, and reconciliation of external patient information, including medications, allergies, immunizations, procedures, diagnoses, and other clinically relevant data.
• Maintains established productivity, quality, and accuracy standards while meeting deadlines and departmental expectations.
• Demonstrates knowledge and appropriate use of the electronic medical record, document imaging systems, health information exchange platforms, and other technology utilized by NH+C.
• Supports medical record integrity initiatives, chart review activities, data collection projects, document management processes, document imaging workflows, and other HIM-related responsibilities as assigned.
• Maintains strict confidentiality of patient information and complies with all HIPAA, privacy, security, regulatory, and organizational requirements.
• Demonstrates the ability to work effectively as a member of an interdisciplinary healthcare team and communicate professionally with providers, leadership, and staff.
• Assists with the receipt, review, indexing, validation, and management of external medical records to support continuity of care and accurate patient record maintenance.
• Supports…