Health Information Abstractor

• Reviews physician and clinical documentation in scanned reports and acquired practices’ legacy medical record to identify pertinent patient information.
• Independently review, analyze, and identify significant patient health information from provider notes, lab results, surgical reports, outpatient notes, and discharge summaries.
• Interprets and documents clinical information from the patient chart such as medications, allergies, procedures, family history and immunizations into discrete fields in the electronic medical record.
• Monitors and maintains charts requiring abstraction for additional data elements after initial encounter is complete.
• Accurately enters health maintenance components into the electronic medical record utilizing appropriate diagnosis and procedure codes.
• Reviews and identifies missing immunizations in the patient chart. Abstracts patient immunizations from the legacy record and historical scanned reports into the state immunization registry and reconciles data into the Epic patient medical record.
• Performs continuous quality checks on charts, analyzes records for errors and facilitates chart corrections as appropriate.
• Utilizes computer systems to access and input patient information. Systems may include patient registration system, Advocate Aurora Health’s Epic electronic medical record, and various affiliation legacy medical record systems.
• Runs Epic reports of pending appointments for affiliation abstracting. Analyzes and provides recommendations for abstracting historical patient information.
• Performs special projects to ensure patient safety and continuity of care.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

• High School Graduate.

Experience Required:

• Typically requires 3 years of experience in allied health that includes experience in electronic medical record data entry, abstracting medical/clinical notes, medical terminology, basic knowledge of human anatomy, physiology, disease processes, and basic knowledge of health information coding. Ability to identify and analyze pertinent health information within the patient record for abstracting. Experience with Epic and/or various ambulatory electronic medical record systems.

Knowledge, Skills & Abilities Required:

• Ability to work independently with minimal supervision and exercise independent judgment.
• Intermediate computer skills including experience in proficiently using Microsoft office or similar products, web browsers, electronic mail and electronic medical record systems.
• Excellent organization skills; ability to work with a high degree of accuracy and attention to detail.
• Must be able to work independently with little or no supervision and utilize good judgment.
• Ability to multi-task and demonstrate good problem-solving skills.
• Ability to analyze patient health information to identify details that are crucial to patient care. Excellent communication (oral and written) and reading comprehension skills.
• Excellent spelling, grammar, and punctuation skills.
• Fast and accurate typing ability.

Physical Requirements and Working Conditions:

• Operates all equipment necessary to perform the job.
• Exposed to normal office environment.

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.