HIM Operations Clinical Data Abstractor I

Carolinas Medical Center; Oak Brook (IL); On-site; USD 32,000 - 47,000; Full time

Job summary

Carolinas Medical Center is seeking a full-time Health Information Management Specialist focused on lab data abstraction and EHR workflow within the HIM Ops Services and Support Lab Data Abstracting team. You will handle electronical health records, ensure accurate lab data entry, and maintain HIPAA-compliant documentation.

The role requires 1–2 years in HIM or lab settings, strong computer skills, and the ability to adapt to evolving requirements.

Qualifications

• Education: High School Graduate or Equivalent.
• Experience: Typically 1–2 years in a Health Information Management or Medical Laboratory setting.
• Knowledge/Skills: Proficient computer and keyboarding; experience with Epic, Extract LabDE, Solarity, OnBase, Microsoft 365 and legacy archives.
• Ability to work independently with attention to detail and accuracy.

Responsibilities

• Navigate EHR and computer applications to support patient care, revenue cycle, and regulatory requirements.
• Receive, sort, scan clinical documentation into the EHR per HIM procedures.
• Analyze lab reports for proper identifiers and compliance with CAP/CLIA requirements.
• Enter data in the EHR, validate components, and ensure PHI protection.
• Locate or create patient encounters, classify documents, and ensure security levels.
• Quality assurance of scanned docs and verify against paper records.
• Communicate with care teams and labs via phone, email, or Epic In-Basket.

Skills

Epic

Extract LabDE

Solarity

OnBase

Microsoft 365

legacy archives

Proficient computer skills

Attention to detail

Education

High School Graduate or Equivalent

Tools

Epic

Extract LabDE

Solarity

OnBase

Microsoft 365

Job description

Department

13533 Enterprise Revenue Cycle - HIM Ops Services and Support Lab Data Abstracting

Status

Full time

Benefits Eligible

Yes

Hours Per Week

40

Schedule Details/Additional Information

Zero Assigned Position requiring a minimum of 24 hours per week on the First Shift, M-F.

Pay Range

$22.90 - $34.35

Major 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 validate 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. Ensure secure retention and destruction of electronic and physical PHI in 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 entry services and other required information.

Minimum Job Requirements

• Education: High School Graduate or Equivalent
• Certification / Registration / License
• Experience: Typically requires 1- 2 years of experience gained through working in a Health Information Management, Medical Laboratory department or other related health care setting.
• Knowledge / Skills / Abilities:
  • 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 while maintaining quality 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

Preferred Job Requirements

• Education
• Experience
• Knowledge / Skills / Abilities

Physical Requirements and Working Conditions

This position requires travel, therefore, will be 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 resp