Qualifications:
Required:
Overview:
Position Description:
- This position supports clinical performance through abstraction, review, and reporting of medical record clinical documentation to support initiatives related to quality improvement, accreditation, and regulatory requirements.
- Scans and imports electronic patient medical records, identifies critical data elements and documents in the medical record, and accurately interprets and abstracts into patient electronic health records.
- Assists with OnBase Document Management and Fax Server training.
Essential Job Functions:
- Abstracts key variables from multiple data sources to create an accurate longitudinal record.
- Participates in developing abstraction project standard operation procedures (SOPs).
- Assists with Chart Audits, performing quality checks on own work and others’ work.
- Performs testing on Epic/OnBase upgrades before moving to production.
- Identifies opportunities with the team to improve processes.
- Communicates effectively with physicians and other health care providers, clinical staff, and outside institutions to obtain proper documentation as needed.
- Facilitates communications between patients, the public, referring physicians, and other health care providers seeking access to services.
- Responsible for accurate and efficient imaging of all medical records and other documents received.
- Prepares, verifies, and maintains records and requisitions to be scanned into OnBase document management software.
- Requests outside records, processes records in time for future appointments, and ensures medical records are appropriately scanned and promptly upon receipt.
- Determines relevant patient documentation and routes to appropriate provider in-baskets.
- Processes ROI requests and handles patient/company phone calls for status checks, problems, issues, etc. Updates phone logs appropriately via Excel spreadsheet.
- Facilitates medical record audits and retrieves paper records from practice locations, inventories, and boxes of paper charts.
- Assists with and assumes additional and special projects to support data entry and compilation of data to develop reports.
- Assists with special projects to support data entry, compilation of data to develop reports, and copying records into or from EHRs as needed.
- Assists with ROI processing or processing of medical record requests and boxing/inventorying paper charts, which may include offsite work.
- Provides support for other departments/practices, as needed, which might include offsite work.
- Attends team meetings to support the department.
- Assists with and assumes additional and special projects as assigned.
Essential Qualifications:
Education:
- High School Diploma or equivalent required.
- Bachelor's degree preferred.
- Prior experience as a medical records abstractor may substitute for education qualification.
Credential/Licensure:
- RHIT Certification or eligibility for RHIT certification is preferred. Medical Assistant certification is also preferred.
Minimum Experience:
- One to three years of experience in a medical office environment is required.
- Prior experience in Medical Records and Data Abstraction is preferred.
Position Requirements (Abilities & Skills):
- Maintains current knowledge of project requirements related to clinical data abstraction.
- Maintains current clinical data abstraction skills.
- Sufficient knowledge of medical terminology, standard medical abbreviations, and pharmacy terms sufficient to identify the proper location of specific health information.
- Sufficient knowledge of mathematics.
- High level of proficiency in operating a standard desktop and Windows-based computer system, including but not limited to EMR/EHR software/templates, NextGen, Epic, Microsoft Word and Excel, intranet, and computer navigation. Ability to use other software as required while performing the job's essential functions.
- Excellent communication skills in both written and verbal forms, including proper phone etiquette. Ability to speak before groups of people, either in-person or virtual.
- Ability to work collaboratively in a team-oriented environment; displays courteous and friendly demeanor.