HIM Operations Clinical Data Abstractor I

Aurora Health Care; Milwaukee (WI); On-site; USD 25,000 - 39,000; Full time

Job summary

Aurora Health Care seeks a Health Information Management assistant to support patient care through accurate data entry and document management in the EHR.

The role involves scanning, validating lab results, and ensuring regulatory compliance while handling PHI securely in a fast-paced healthcare setting.

Qualifications

• High School Diploma or Equivalent.
• 1–2 years in Health Information Management or Medical Laboratory setting.
• Proficient with Epic, OnBase and other clinical software.

Responsibilities

• Navigate EHR and computer applications to support patient care and care management initiatives.
• Receive, sort, prepare, and scan documents into the EHR per HIM procedures.
• Analyze non-interfaced lab reports to ensure patient identifiers and regulatory compliance.
• Enter and validate data in the EHR with correct order templates, units, and reference ranges.
• Classify and secure PHI, ensure HIPAA compliance and proper destruction of records.
• Perform quality assurance to ensure scanned documents match patient records and are accurate.
• Communicate with care teams and laboratories via phone, email, or Epic In-Basket as needed.

Education

High School Diploma or Equivalent

Tools

Epic

ExtractLabDE

Solarity

OnBase

Microsoft 365

Job description

Major Responsibilities

Navigates various electronic health record (EHR) and computer applications to perform job duties to support patient care, care management initiatives, revenue cycle,HealthMaintenanceand 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 includingHealth 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

Experience

Typically requires 1- 2 years of experience gained through working in aHealth Information Management,MedicalLaboratorydepartment 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, ExtractLabDE,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

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.