Abstractor Job Description Sample
Based upon the Database or Registry glossary and the guidelines required by regulatory agencies, the
Abstractor will collect specific data elements from the electronic health record of the qualifying patientpopulation. The Abstractor is responsible for the accurate interpretation of the definitions in order to performreliable, valid abstraction of the required elements. The Abstractor must achieve and maintain a 95 percentaccuracy rating for each type of abstraction. The Abstractor collaborates with clinical staff such as physicians,nurses, pharmacists and also other hospital support staff. The Abstractors are responsible for coordinatinginter-rater Reliability Audits as assigned. They are also responsible reporting issues and documentation errorsto appropriate clinical staff.
Acts as an information and system resource about the guidelines and procedures for each registry for members of the organization andfor peers outside of the organization. The Responsibility and Accountability meets standards when:
Provides expert opinion related to abstracting definitions, guidelines and required documentation to physicians and clinical staff to assurecompliance.
Attends multidisciplinary meetings that involve review and/or analysis of registry data.
Acts as a resource to other organizations to discuss abstracting systems, methods and processes as requested.
Works with the IT staff to develop ways to improve the accuracy of the electronic submissions, validate worklists for correct population, and simplify the documentation to make data more discreet and fit the clinician workflow.
Documents monthly, quarterly, and comparative data on SharePoint for committees in a timely manner.
Documents non-compliance issues on Share Point for clinicians to make improvements to prevent future non-compliance.
Communicates with the entire abstraction staff changes in the EPIC system that may affect abstraction.
Participates in registry related conferences, calls, or webinars, as well as attending National conferences as requested.
Communicates changes with involved team including clinicians.
Acts as an information and system resource about the guidelines and procedures for each registry for members of the organization and for peers outside of the organization.
Completes the expected number of abstractions based on hours worked with minimal non-abstracting time.
Maintains accuracy of abstraction following established agency regulations.
Responsibilties related to Employee Health include:
Responsible for Fit tsting of staff
Assist the Director of Employee Health/Infection Control duties as assigned
Assist the Quality Director duties as assigned
Education RequirementsHigh School Diploma or GED (Required)LPN RequiredExperience and Skills1-3 Years Knowledge and experience with Microsoft Office Applications including Word, Excel, Outlook(Required)
1-3 Years Medical terminology, anatomy, physiology, disease processes. (Required)
Excellent Communications Skills, Excellent Interpersonal Skills, General Clerical Skills,Microsoft Excel, Microsoft PowerPoint, Microsoft Word
Based upon the Database or Registry glossary and the guidelines required by regulatory agencies, the
Abstractor will collect specific data elements from the electronic health record of the qualifying patientpopulation. The Abstractor is responsible for the accurate interpretation of the definitions in order to performreliable, valid abstraction of the required elements.
The Abstractor must achieve and maintain a 95 percentaccuracy rating for each type of abstraction. The Abstractor collaborates with clinical staff such as physicians,nurses, pharmacists and also other hospital support staff. The Abstractors are responsible for coordinatinginter-rater Reliability Audits as assigned. They are also responsible reporting issues and documentation errorsto appropriate clinical staff.
High School Diploma or GED (Required)Knowledge and experience with Microsoft Office Applications including Word, Excel, Outlook (Required)
Knowledge of medical terminology, anatomy, physiology, disease processes (Required)
Excellent Communications Skills, Excellent Interpersonal Skills, General Clerical Skills,Microsoft Excel, Microsoft PowerPoint, Microsoft Word
The Chattanooga Heart Institute
Full Time - First Shift
Responsible for interpreting and analyzing records on a daily basis for assigned physicians. Assists other healthcare professionals regarding patient assessments in order to document patient care and facilitate delivery of healthcare services. Chart work up, patient information retrieval and chart abstraction.
Process requests for medical records both outgoing and incoming from multiple sources.
Import test results into Electronic Health Record (EHR) in a timely manner.
Field incoming calls from patients, nurses and other medical facilities and provide friendly service and support.
Provide support in locating medical records from internal and external sources as needed.
Provide support in obtaining records from outside sources to complete chart for patient care.
Meet quality and productivity standards as established by the department.
Analyze patient medical records for physician appointments on a daily basis. Analyze, retrieve, and scan needed HIM records in order to facilitate completeness of patient chart for patient care..
Contact appropriate areas to obtain needed information such as Cath films and CD's. Use of multiple software products, including but not limited to Chartmax, Meditech, McKesson, Cerner and other systems as needed to obtain hospital information and office procedures.
Follow established policies and procedures to contribute to the efficiency of the HIM Department.
Ability to understand various reports and place them in appropriate categories in Document Management.
Work closely with clinical staff and Physicians to ensure clinical abstraction is complete and correct.
Abstract data into the EHR according to established procedure.
Assign diagnosis codes to problems, per ICD-10 guidelines.
Provide administrative/clerical/technical support as assigned.
Use reference material appropriately and efficiently to facilitate accuracy, clarity and completeness of reports.
Interact effectively with physicians, nurses, other staff and patients and their family members in person and over the phone.
- Associates degree in RHIT program preferred but other degreed programs accepted
- One year experience with EHR and chart abstraction in a medical practice setting.
- RHIT certification or equivalent experience with chart workup and abstraction with an associate level degree.
Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
Adheres to and exhibits our core values:
Reverence: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
Integrity: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
Compassion: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.
Excellence: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
Maintains confidentiality and protects sensitive data at all times.
Adheres to organizational and department specific safety standards and guidelines.
Works collaboratively and supports efforts of team members.
Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.
This position requires a criminal background check. Therefore, you may be required to provide information about you criminal history in order to be considered for this position.
Catholic Health Initiatives and its organizations are Equal Opportunity Employers(F/M/Vet/Disabled)CBCHI
Abstractor VI (Sr-15) - Oahu
Recruitment Number 217433 - Downtown, Island of Oahu Employment Only.
Note: The starting monthly salary is at the minimum rate of pay advertised above.
A continuous recruitment may be closed at any time. The notice of the last day to file applications will be posted on the Civil Service Hawaii State Government Jobs page of our website.
Examines land titles by searching public records, examining legal documents, and summarizing and recording pertinent information from these documents that are essential to determining ownership and condition of title to land subject to acquisition by the State; prepares worksheets showing the history of the title and all encumbrances, restrictions and covenants affecting the titles; reviews land transaction documents for purposes of indexing information reflecting changes in land ownership or land titles; and performs other related duties as assigned.
Minimum Qualification Requirements
To qualify, you must meet all of the following requirements:
General Experience: Two (2) years of progressively responsible work experience involving one or a combination of the following: a) preparing; b) reviewing; or c) extracting information from legal documents and/or records dealing with real property ownership or transactions.
Specialized Experience: Two (2) years of progressively responsible work experience involved in the examining and analyzing of real property ownership records and documents to determine and evidence title to real property.
Substitutions Allowed: Relevant substitutions as described in the Minimum Qualification Requirements will apply.
Lifting and Carrying: Applicants must be able to lift and carry objects weighing up to 40 pounds unassisted, with or without reasonable accommodation.
The information provided above represents a summary of the Minimum Qualification Requirements. To view the Requirements in their entirety, please CLICK HERE.
PUBLIC SERVICE LOAN FORGIVENESS (PSLF) PROGRAM
The PSLF Program is a federal program that is intended to encourage individuals to work in public service by forgiving the balance of their federal student loans. To qualify, the individual must have made 120 qualifying payments while employed by a qualifying employer. For more information, please click: https://studentaid.ed.gov/sa/repay-loans/forgiveness-cancellation/public-service
ELECTRONIC NOTIFICATION TO APPLICANTS
The Department of Human Resources Development (HRD) will use electronic mail (email) to notify applicants of important information relating to the status and processing of their applications as part of our ongoing efforts to increase operational efficiency, promote the conservation of green resources, and minimize delays and costs.
Please ensure that the email address and contact information you provide is current, secure, and readily accessible to you. We will not be responsible in any way if you do not receive our emails or fail to check your email-box in a timely manner. In addition, please be aware that you may no longer receive notification about applications submitted if you choose to disable the Job Application Emails feature in your Account Settings.
The examination for this recruitment will be conducted on an unassembled basis where the examination score is based on an evaluation and rating of your education and experience. It is therefore important that your employment application provide a clear and detailed description of the duties and responsibilities of each position you held.
In-person interviews and/or further testing in Hawaii may be required at the discretion of the hiring agency. If in-person interviews and/or further testing are required, applicants who meet the minimum qualification requirements and are referred to the vacancy must be available to participate in person and at their own expense in this phase of the selection process.
Applicants are encouraged to submit their applications as soon as possible. In addition to employment availability and score, the referral of qualified applicants may be based upon other factors including date of receipt of the application.
The State of Hawai'i complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If you require reasonable accommodations in completing an application, any pre-employment testing, or otherwise participating in the selection process, please call 808-587-0936 for assistance.
CLICK HERE for further information about Equal Employment Opportunity, the Merit Civil Service System, Citizenship and other requirements, Reasonable Accommodation, Veterans Preference, Examination Requirements, and the State Recruiting Office's Levels of Review.
Neuro Abstractor - Neuroscience Unit, Full-Time, Days
Reviewing comprehensive data related to stroke patients from the EMR, medical records, and other source documents to collect data of patients in the stroke program according to the specifications and guidelines of the applicable data element. Responsible for accurate collection of stroke data through concurrent and retrospective review.
Enters data into the electronic database(s) to include data required by regulatory agencies and data used for internal program monitoring, improvement, and special initiatives. Assists in data analysis and preparation of reports for Stroke Quality Committee, team reports, special initiatives and other committees as needed. Assists with Joint Commission and other survey preparations maintains patient lists, call back log and other data bases.
Responsible to remain up to date with data definitions as related to abstraction of the data. AA/EOE.
Required: 1 year experience coding inpatient and or observation/ambulatory surgery medical records or data abstraction or similar experience. Proficient in Excel, Access, Word and Power Point.
Manage interpersonal relationships and interact/communicate with clarity, tact, and courtesy with patrons, patients, staff, faculty, students, and others required. Communicate effectively in English, both orally and in writing required.
Ability to identify priorities and recognize and resolve/refer problems required.
Ability to work effectively with supervision and as part of a team required. Preferred: 3 years experience coding inpatient and or observation/ambulatory surgery medical records or data abstraction or similar experience.
Quality Data Abstractor
Core Duties and Responsibilities
The ideal candidate for this position is highly organized, self-directed and able prioritize, meet deadlines, communicate proactively and follows up with minimal direction
Responsible for accurately abstracting clinical data from hospital electronic medical record systems, and paper-based medical records.
Maintains knowledge of abstraction standards and requirements, as well as accurate collection of data from medical records for summary analysis and public reporting.
Maintenance of database information related to abstracted data.
Works closely with staff in the Quality department to resolve abstraction questions and communicate concerns or trends with abstracted data.
Performs concurrent and retrospective case reviews based on generic screens, clinical indicators, focused studies, physician or outcome issues and occurrence reporting.
Conducts daily and concurrent chart audits to ensure compliance with internal and external regulatory standards.
Maintains and validates data for eCQM submission
Completes other duties as may be assigned.
High School Diploma or equivalent
2 years' experience in an acute healthcare setting
RHIT certification and coding experience preferred
Certified as a Medical Assistant (MA), Certified Nursing Assistant (CNA), or Medical Coding Certification (AAPC)
CMS Inpatient and/or Outpatient Quality Reporting programs (IQR/OQR) experience preferred
Knowledge of Cerner applications/EHR
Knowledge of medical terminology, standard medical abbreviation and pharmacy terminology
Working knowledge of clinical workflows to understand types of health information
Ability to work effectively and collaboratively with colleagues and department heads required.
Proficiency with Microsoft Outlook, Word, Excel, and Internet Explorer
Exemplary core customer service skills strongly required
Strong organizational, verbal and written communication, and time management skills
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required.
This job description should not be construed as an exhaustive statement of duties, responsibilities or requirements, but a general description of the job. Nothing contained herein restricts the company's rights to assign or reassign duties and responsibilities to this job at any time.
Shore Medical Center is an Equal Opportunity Employer. All applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, gender identity, affectional or sexual orientation or sex.
Are you an experienced Lease Abstractor? RHL has an exciting opportunity for a Lease Abstractor at a Commercial Real Estate company located in Seattle, WA. Located onsite for a Seattle-based online retailer client, this role adds to a team of Real Estate and Legal professionals. The following are responsibilities and qualifications/previous experience that would be ideal for this position: - Quality Checking lease abstraction work from a third party
High attention to detail
Previous lease abstraction experience (or abstraction of other contracts would be helpful in this role)
Experience in the Real Estate/Leasing space If you are looking for a rare opportunity to build your experience in Real Estate, Leasing, and Legal/Contracts space, apply today! This role has great long-term potential. To apply - email your resume to for immediate consideration!
Previous Real Estate/Leasing Experience
Experience in abstracting information/terms from leases and/or legal contracts
Employment Type: Contract Legal Professionals
POSITION SUMMARY: The Abstractor Specialist assists the Health Information Management Department (HIM) in coding, abstracting completion and birth record completion activities.
The position is responsible for reviewing, analyzing hybrid medical record (electronic and paper based), identifying and following through on documentation deficiencies. Abstract Specialist translates documentation into alpha-numeric codes for each diagnosis to satisfy hospital compliance, internal and external data collection and reporting requirements of state and federal agencies, as well as to enable hospital billing.# Abstract Specialist must be knowledgeable and competent in utilizing appropriate coding classification and grouping systems.# The position reports directly to the Coding/Data Management and works with Senior Coders. # EDUCATION/CERTIFICATION ######## Requires High School Diploma or GED equivalent, some successful college level course completion in specialized Medical Health subjects is preferred, such# as Anatomy, Physiology, Medical Terminology and disease processes.. ######## Requires International Classification of Diseases (ICD) # ICD-9-CM successful course completion
-10-CM (Diagnosis) successful college level course completion# # EXPERIENCE ######## A minimum of two years experience in acute care hospital abstracting, coding, charging and health information systems is required.# # COMPETENCIES ########### Coding knowledge and skills must be continually updated in order to remain proficient and accurate in the Collection of data specific to regulatory standards. ICD-9-CM, ICD-10-CM knowledge and experience.
Must be experienced in the use of a personal computer and proficient in Windows based Microsoft software programs and have experience in outpatient hospital coding
, reimbursement and health information systems.# ######## Must be an excellent reader with comprehension and memory skills, be able to read, speak and write proficiently in English in order to effectively communicate on a daily basis with hospital staff, physicians, providers, patients and visitors.# ######## Detailed work requires ability to concentrate for long periods of time.# ######## Must act independently and be able to make sound decisions objectively and follow through.# ######## Acts as the liaison with coding and charging vendor, Medical Staff, Clinical and Financial Departments.
Travel between work sites may be required exposing the employee to varying outdoor climate conditions beyond the control of the employer
, making reliable transportation a requirement.
ESSENTIAL DUTIES and RESPONSIBILITES:
Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job.# They are intended to be accurate reflections of the principal duties and responsibilities of this position.# These responsibilities and competencies listed below may change from time to time. # ######## Reviews medical record documentation (electronic and paper based) and adheres to strict data quality definitions and requirements.# Communicates documentation, medical record and account deficiencies within HIM, to providers, clinical and financial departments.
Uses appropriate coding classification system
(ICD) and grouping systems.# Enters diagnoses, charge codes and required data elements in database for all patient encounters.
Supports accounts receivable
, in a compliant fashion.# Prioritizes monthly and year-end coding and abstracting activity by adjusting to different account types and priorities.
Demonstrates a commitment to maintaining competency in health care coding and classification systems
, including ICD-CM, and relationship in outpatient grouping and billing.# Reviews references, attends
continuing education and keeps current with coding and reimbursement practices
, sequences and abstracts diagnosis and procedure codes and demonstrates the ability to effectively utilize coding software and coding references while reviewing medical record documentation specific to account.
Supports HIM Department coding and abstracting efficiencies
.# Demonstrates quantitative and qualitative performance. Demonstrates a commitment to individual and team job performance meeting productivity and quality standards.# Completes required documentation and provides to Senior Coder.
Supports HIM Department vendor production and compliance
.# Participates in abstracting validation of vendor data to include assigned diagnosis and procedure codes.
Reviews medical record to determine required Birth Record data collection
.# Enters data elements in State of# Connecticut data base (EVRS) to support timely and quality filing referencing appropriate medical record documents to assure daily and monthly data collection for all birth encounters.
Supports the hospital CHIME Error Identification and Correction process relative to mandatory abstract reporting and data completion schedule
. Prioritizes error review and corrections, researches problems and refers unresolved issue to Senior Coder.
Reviews Meditech reports to determine account coding and abstracting delays
.# Works to resolve account requirements and provides detail to Senior Coders if further account reconciliation required.
Supports HIM Department medical record filing practices to support retrieval and retention
.# Follows departmental procedures to assure medical records are located in designated areas. #
Cancer Registry Abstractor
PURPOSE: The Cancer Registry Abstractor performs all Cancer Registry functions in compliance with national, state, and local regulations and administrative law, including casefinding, suspensing, abstracting, and quality control.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Utilize patient lists (disease indices) for casefinding
Review applicable EMR, and when necessary paper medical records, and state reporting manual(s) to determine reportability of all cases from disease indices, and for abstracting
Suspense applicable cases into 21st Century Oncology electronic cancer registry database (CRStar)
Utilizing all applicable manuals, complete abstracts on all applicable reportable conditions according to guidelines established by National and State Cancer Registry Standard Setters
Participate in quality control by insuring all applicable data edits are resolved for every case abstracted
Actively participate in ongoing education and training to improve skills, and gain new skills in keeping with continuous Cancer Registry updates and changes
Other duties as assigned
Good computer skills
Anatomy and Physiology
Experience with Office: Outlook, Excel, Word
Knowledge of Paper and Electronic Medical Records
Knowledge of Cancer Registry Software
Knowledge of ICD-10 Coding
Knowledge of Cancer Registry reporting manuals
Ability to work independently, with direct supervision as needed
EDUCATION AND/OR EXPERIENCE:
Minimum High School Diploma Required
Successful completion of a National Cancer Registrar's Association (NCRA) Accredited Associate Degree Program, or, minimum of an Associate degree or equivalent (60 college-level credits) including two semesters of Human Anatomy and Human Physiology or equivalent with Grade C or better, preferred
At least 1 year Cancer Registry experience preferred
CONFIDENTIAL AND SENSITIVE INFORMATION:
Must maintain patient confidentiality at all times
Must properly control the release of proprietary and confidential information
- Must have excellent verbal and written communication skills
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Job Description Clause
The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of the employer.
Cancer Registry Certified Data Abstractor - Work From Home
- This position is responsible for case finding and abstraction of cancer data for HCA hospitals.
- Cancer Registry Director
Duties (included but not limited to):
- Completes case-finding for assigned facilities, including review of pathology reports, the disease index,
suspense list in Meditech and merging appropriate cases into Metriq.
- Responsible for reviewing medical records to abstract information according to the standards of the
American College of Surgeons (ACOS) and the appropriate State Cancer Data System.
- Performs timely abstraction of assigned cases to ensure compliance with ACOS standards, i.e. within
six months of patient contact.
Completes edit checks and makes appropriate changes on a timely basis.
Follow ACOS and state data standards and coding instructions to abstract all reportable cases.
Assist with case follow-up of analytic patients as requested.
Attend state and national educational activities as approved by Director.
Submit data to the National Cancer Data Bank (NCDB) in accordance with the annual Call for Data.
Submit data monthly to the appropriate State Cancer Data System.
Resolve errors resulting in the rejection of records from the NCDB and the state data systems.
Participates in required continuing education programs, and annual reorientation.
Practice and adhere to the "Code of Conduct" philosophy and "Mission and Value Statement"
Other duties as assignedKNOWLEDGE, SKILLS & ABILITIES
Knowledge of disease index and pathology reports.
Computer skills, including data input, Meditech and other required software.
- High school degree (or equivalent) required; Associates degree preferred
- 3-5 years of Cancer Data Abstraction or Medical Records experience
Certified Tumor Registrar (CTR) designation required.
PHYSICAL DEMANDS/WORKING CONDITIONS - Requires prolonged sitting, some bending, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports. Requires lifting papers or boxes up to 50 pounds occasionally. Work is performed in an office environment. Work may be stressful at times.
Page 1 of 2 Cancer Registry Certified Data Abstractor New: 2/01/2018
Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations.
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