Job Description
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 key data elements and documents in the medical record and accurately interprets and abstracts into IHA 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 the development of 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 prior to 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, public, referring physicians and other health care providers seeking access to IHA 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 scanned properly 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 log appropriately via Excel spreadsheet.
Facilitates medical record audits, retrieves paper records from practice location; inventories and boxes 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 EHR's 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.
ORGANIZATIONAL EXPECTATIONS:
Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the mission and values of both IHA and Trinity Health.
Must be able to work effectively as a member of the Central Medical Records team.
Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.
Maintains knowledge of and complies with IHA standards, policies and procedures.
Maintains complete knowledge of office services and in the use of all relevant office equipment, computer and manual systems.
Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines.
Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respects cultural differences.
Uses resources efficiently.
If applicable, responsible for ongoing professional development - maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.
MEASURED BY:
Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.
ESSENTIAL QUALIFICATIONS:
EDUCATION: High School Diploma or equivalent required. Bachelor's degree preferred. Prior experience as medical records abstractor may substitute for education qualification.
CREDENTIALS/LICENSURE: RHIT Certification or eligible for RHIT certification preferred. Medical Assistant certification also preferred.
MINIMUM EXPERIENCE: One to three years' experience in a medical office environment required, with at least one year IHA seniority. Prior experience in Medical Records and Data Abstraction 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 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 essential functions of the job.
Excellent communication skills in both written and verbal forms, including proper phone etiquette. Ability to speak before groups of people, either in-person or virtually.
Ability to work collaboratively in a team-oriented environment; displays courteous and friendly demeanor.
Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, family members, insurance carriers and vendors.
Ability to effectively transition between office locations.
Ability to cross-train in other areas of practice in order to achieve smooth flow of all operations.
Good organizational and time management skills to effectively juggle multiple priorities and time constraints.
Ability to exercise sound judgement and problem-solving skills, specifically as it relates to interpreting customer issues and applying a solution.
Ability to handle patient and organizational information in a confidential manner.
Successful completion of IHA competency-based program within introductory and training period.
Ability to travel to other office/practice sites and meeting and training locations.
MINIMUM PHYSICAL EXPECTATIONS:
Physical activity that often requires keyboarding, filing and phone work.
Physical activity that often requires extensive time working on a computer.
Physical activity that sometimes requires walking, standing, bending, stooping, reaching and/or twisting.
Physical activity that sometimes requires lifting, pushing and/or pulling under 30 lbs.
Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus.
Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.
Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.
MINIMUM ENVIRONMENTAL EXPECTATIONS :
This job operates in a typical office environment which involves frequent interruptions and significant interaction with people which can be stressful at times.
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