Qualifications:

Required:

• High School/GED

• Valid Registered Health Information Technician (RHIT)

• Any of the following valid licenses/certifications:

  • Certified Medical Assistant (CMA)

  • Registered Medical Assistant (RMA)

  • Certified Medication Aide (CMA)

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.