HIM Operations Clinical Lab Data Abstractor I

Aurora Health Care; Milwaukee (WI); On-site; USD 36,000 - 48,000; Full time

Job summary

Aurora Health Care is seeking a detail-oriented Health Information Technician to support patient data entry, lab results, and chart management within the EHR environment, ensuring accurate documentation in a fast-paced setting.

The role requires a High School Diploma or equivalent, 1–2 years in Health Information Management or Medical Laboratory settings, and proficiency with Epic, ExtractLabDE, Solarity, OnBase and Microsoft 365; travel may be required and strict HIPAA/privacy adherence is

Qualifications

• High School Diploma or equivalent is required.
• 1–2 years of experience in Health Information Management or Medical Laboratory settings.
• Proficiency with HIM software and EHR systems including Epic, OnBase, and Microsoft 365.

Responsibilities

• Navigates various EHR and computer applications to support patient care and HIM processes.
• Receives, sorts, prepares, and scans documentation into the EHR per HIM procedures.
• Analyzes laboratory reports and ensures patient identifiers and regulatory compliance.
• Enters laboratory orders and data accurately within the EHR.
• Abstracts and imports results, flags abnormal findings, and alerts clinicians.
• Manages patient, encounter, and order data with proper security for PHI under HIPAA.
• Ensures timely QA of scanned documentation and validates accuracy against paper records.
• Performs error correction, with secure retention and destruction of PHI as required.
• Communicates with care teams and external labs via multiple channels for data entry and education.

Skills

Epic proficiency

Attention to detail

Work under pressure

Independent work

Team collaboration

Feedback oriented

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.