Abstractor Job Description Sample
Position Type: Regular
Scheduled Hours per 2 week Pay Period: 80
Primary Location: TN > CHATTANOOGA > CHATTANOOGA HEART - MAIN
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, organizationvalues and professionalism through appropriate conduct and demeanor at alltimes.
Adheres to and exhibits our core values:
Reverence: Having a profound spirit of awe and respect for allcreation, shaping relationships to self, to one another and to God andacknowledging that we hold in trust all that has been given to us.
Integrity: Moral wholeness, soundness, uprightness, honesty andsincerity as a basis of trustworthiness.
Compassion: Feeling with others, being one with others in theirsorrows and joys, rooted in the sense of solidarity as members of thehuman community.
Excellence: Outstanding achievement, merit, virtue; continuallysurpassing standards to achieve/maintain quality.
Maintains confidentiality and protects sensitive dataat all times.
Adheres to organizational and department specificsafety standards and guidelines.
Works collaboratively and supports efforts of teammembers.
Demonstrates exceptional customer service and interactseffectively with physicians, patients, residents, visitors, staff and thebroader health care community.
Thisposition requires a criminal background check. Therefore, you may be required to provide information about you criminalhistory in order to be considered for this position.
CatholicHealth Initiatives and its organizations are Equal Opportunity Employers(F/M/Vet/Disabled)CBCHI
Requisition ID: 2018-R0190351
Market: CHI Memorial
The Abstractor will be responsible for reviewing the Inpatient/Outpatient medical record and abstract data that is required into the Cerner Abstracting system before/after Coding has been completed. The Abstractor performs both Pre-Abstracting and Post-Abstracting based on their assignment by the Team Leader.
The Abstractor will ensure that the Discharge Disposition is accurate, Inpatient Admission order is present and gather additional information that is needed prior to finalizing the Abstracting working closely with Coding and Audit/Compliance if needed. This position could be assigned to assist with coding Outpatient Lab accounts and Pre-admits as requested. The Abstractor will report to the Team Leader-Abstracting/Coding Support and/or IP/OP Coding Supervisors.
Required: High School Diploma
Required: Prior HIM experience working with Analysis, Coding Support or Document Imaging
Preferred: Coding course completion
Visual acuity necessary to read and decipher handwriting and electronic documentation.
Demonstrates competency with use of computers and various computer programs.
Excellent written and verbal communication skills, including the ability to present ideas and concepts effectively.
Must have the analytical ability to interpret data contained in medical records and assign appropriate codes for accurate reimbursement.
Understanding ICD-10-PCS (Inpatient Coding) and ICD-10-CM (Inpatient Coding) classification systems.
Preferred: AHIMA Coding Credential:
CCS or AAPC Coding Credential: COC or CPC.
Job Benefits & Perks!
Tuition Reimbursement up to $1200 per year
Retirement with employer match
Onsite daycare with extended hours, holidays and weekends
Onsite fitness facilities
Pharmacy delivery to your department
Onsite Employee Health services
Opportunity to earn referral bonuses up to $5000 per hire for certain positions
1906 Employee Store
20% tuition discount on most classes at Cox College
35% cafeteria discount
Abstracts clinical data from medical records in accordance with regulatory and administrative reporting requirements.
- Abstracts key clinical findings accurately and in a timely manner and performs direct data entry for inclusion into an aggregate database to meet the requirements of the state, internal use, third party payer requirements and external quality improvement participation based on guidelines. (80%)
- Performs system functions and report running as needed. (10%)
- Participates in ongoing data quality studies to ensure an accurate database. (10%)
- Performs other duties as assigned or required.
- High school diploma or equivalent.
Successful completion of college-level courses in Anatomy & Physiology and Medical Terminology.
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).
Minimum 1 year abstracting experience preferred. Minimum 1 year medical record experience.
Proficient in the use of computer systems to include GroupWise, Microsoft Office, mainframes and the electronic medical record.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org
Based upon the Database or Registry glossary and the guidelines required by regulatory agencies, the QI Abstractor will collect specific data elements from the electronic health record of the qualifying patient population. The Abstractor is responsible for the accurate interpretation of the definitions in order to perform reliable, valid abstraction of the required elements.
The Abstractor must achieve and maintain a 95 percent accuracy 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 coordinating inter-rater Reliability Audits as assigned. They are also responsible reporting issues and documentation errors to appropriate clinical staff.
High School Diploma or GED (Required)1-3 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
RN Clinical Data Abstractor - Quality Outcomes Data & Registries (Vancouver, WA, US)
PeaceHealth is seeking a RN Clinical Data Abstractor
- Quality Outcomes Data & Registries for a 0.9 full time equivalent Exempt position. This position will be working Day shift with shift durations of Variable.
Req ID: 171712
Responsible for abstracting and/or auditing a large volume of clinical case records, data, or other information within established deadlines in support of PeaceHealth's quality assessment and performance improvement program and compliance with regulatory and accreditation requirements. Applies clinical training, knowledge and clinical experience in the review of moderate to highly complex clinical information from individual patient records and other sources to abstract data elements for clinical registries and to ensure compliance with standards of care, policies and procedures, regulations or accreditation requirements. Produce reports addressing variances from established standards, and identify significant data trends, outlier values or unusual data for additional review by physicians, clinical value improvement staff and/or leadership. Responsible for the integrity of the reported data.
1.Manage, schedule and receive patient records for abstracting from multiple PeaceHealth hospitals; abstract moderate to highly complex clinical data using established definitions and abstraction guidelines; maintain an abstracting volume to meet internal and external reporting deadlines.
2.Enter abstracted data into the appropriate registry or third-party vendor software within the established deadlines for data submission.
3.Conduct or coordinate audits of patient records or other information to support the quality assurance and performance improvement program in each PeaceHealth community and evaluate compliance with established standards and/or regulatory and accreditation requirements.
4.Identify potential areas of concern/interest; interpret actual trends and develop reports that display variances from established standards of care or regulatory standards; summarize findings and draw conclusions; maintain ongoing variance reports and communicate findings to provider, clinical value improvement caregivers and/or leadership in a timely manner; work with providers to interpret data trends and/or variances.
5.Maintain accuracy in abstraction by following published guidelines and abstraction specifications; maintain accuracy and integrity of audit information by following standards and guidelines; facilitate and participate in quality assurance audits of abstracted/audited data to ensure a high level of inter-rater reliability among the clinical data abstractor team and achievement of acceptable validation results from external audits.
6.Create case finding or internal audit reports in an acceptable format for additional review by providers, clinical value improvement caregivers and/or leadership.
7.Participates in teleconferences, webinars, and/or onsite educational opportunities. Share knowledge with clinical value improvement caregivers and teams.
8.Create and support an environment that fosters and supports teamwork; works collaboratively with providers, clinical value improvement caregivers, health information management, and operational leaders.
9.Participate in team or committee meetings to present and discuss data and identify trends as appropriate.
10. Perform other duties as assigned.
- Minimum of Associates degree in Nursing required; Bachelor's Degree in Nursing strongly preferred
Minimum of three years clinical experience in an acute care hospital with preferred experience in surgery, inpatient care, and emergency services. Clinical experience must be recent enough to demonstrate knowledge of current clinical practice standards or demonstration of adequate continuing education.
An Advanced Nurse Practitioner degree may be substituted for preferred experience.
Care management and/or hospital insurance case management experience may be substituted for clinical experience. However either must reflect competence in current clinical practice.
Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity strongly preferred. Physician Focus position; information systems experience and knowledge is preferred.
- Current Registered Nurse licensure in the state the nurse will be working.
- CPHQ certification preferred.
Advanced knowledge of medical terminology, anatomy and physiology and understanding of disease processes, pharmaceuticals, and diagnostic studies.
Strong organization, analysis, software aptitude, and communication skills (both written & verbal).
Proficient skills in database management, spreadsheets, word processing, graphs and presentations.
Proficient with MS Office applications.
Demonstrated experience working successfully with physicians and clinicians required.
Current knowledge of regulatory and accreditation requirements related to data abstraction and reporting, quality assurance, performance improvement and required measurement systems.
SHARED SERVICES - PHYSICAL/COGNITIVE REQUIREMENTS
Work requires fairly light physical exertion from up to 65% of the time.
Ability to lift objects weighing 30 lbs. or less.
Work is performed under normal working conditions with adequate lighting and ventilation.
Job duties frequently require intense concentration and attention to detail (up to 65% of work time).
Please apply online to be considered. For full consideration of your skills and abilities, please attach a current resume with your application.
PeaceHealth, based in Vancouver, Wash., is a not-for-profit Catholic health system offering care to communities in Washington, Oregon, and Alaska. PeaceHealth has approximately 16,000 caregivers, a multi-specialty medical group practice with more than 900 providers and 10 medical centers serving both urban and rural communities throughout the Northwest. In 1890, the Sisters of St. Joseph of Peace founded what has become PeaceHealth. Today, PeaceHealth is the legacy of its founding Sisters and continues with a spirit of respect, stewardship, collaboration and social justice in fulfilling its Mission.
We offer competitive compensation, a robust benefits package and a collaborative, Mission-driven work environment! To learn more about working at PeaceHealth and the Vancouver community please visit our homepage: www.peacehealth.org/careers.
Get a feeling for the Spirit of PeaceHealth through this three-minute video, and visit us on Facebook or LinkedIn!
Questions? Review our Employment FAQ or email Recruitment@peacehealth.org. Please note this email does not accept resumes or applications.
Location: Vancouver, Shared Services Center (802)
Job Category: Business, Administrative & Facilities
Shift Length: Variable
Work Type: Full Time
Hourly compensation starts at: $36.26, more depending on experience
Required Certifications/Licensure: Registered Nurse
PeaceHealth is committed to providing equal employment opportunities to all qualified job applicants and employees without regard to the following statuses: protected veteran; qualified individual with a disability; race; ethnicity; religion; gender; pregnancy; gender identity; national origin; age; genetic information; sexual orientation; or any other protected status in accordance with local, state, or federal laws.
The above information is intended to indicate the general nature and level of work performed by this position. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.
Posting Notes: Vancouver || Business, Administrative & Facilities || Risk Management & Quality || Full Time || QUALITY IMPROVEMENT
ENTRY REQUIREMENTS This position requires an Associates Degree in Health Information Technology or equivalent, or a Bachelors Degree in Health Information Management preferred. # Certification as a Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) is required. # One to three years previous experience using ICD-9-CM and CPT-4 coding systems is required. # Demonstrated ability to meet productivity and quality standards is required. # Keyboard entry skills are required. # Previous abstracting experience is preferred. # Previous experience with a computerized encoder system is preferred. # # ORGANIZATION # Reports to the Manager of Medical Record Services.# Has constant working contact with Coding Analyst.
POPULATIONS SERVED COMPETENCIES
, INCLUDING AGE OF PATIENTS SERVED # #### Cares for patients in the age category(s) checked below: # ###### __Neonatal (birth-1 mo)########################### __Young adult (18 yr-25 yrs) ###### __Infant (1 mo-1 yr)################################ __Adult (26 yrs-54 yrs) ###### __ Early childhood (1 yr-5 yrs)################# ########### __ Sr. Adult (55 yrs-64 yrs) ## ###### __Late childhood (6 yrs-12 yrs)################ __Geriatric (65 yrs # above) ###### __Adolescence (13 yrs-17 yrs)################# __All ages (birth # above) ###### _X_No direct clinical contact with patients # # # SPECIFIC DUTIES # Supports the Mission, Vision and Values of Munson Healthcare # Embraces and supports the Performance Improvement philosophy of Munson Healthcare. # Promotes personal and patient safety. # Has basic understanding of Relationship-Based Care (RBC) principles, meets expectations outlined in Commitment To My Co-workers, and supports RBC unit action plans. # Uses effective customer service/interpersonal skills at all times. # Analyzes each medical record to determine which items will be coded and abstracted. # Accurately codes and abstracts inpatient, outpatient or emergency medical records, per work assignment, meeting expected productivity standards. # Assigns ICD-9-CM diagnosis and procedure codes and CPT-4 procedures codes, per established national, departmental guidelines and AHIMA Code of Ethics. # Abstracts and/or edits medical record data as required by departmental procedure. # Communicates with physicians to request clarification and/or additional record information that will ensure correct code assignment, appropriate reimbursement and compliance with established guidelines.# This applies to ICD-9 and CPT coding. # Maintains organized system for personal coding reference material. # Participates in educational activities and maintains coding skills. # Performs other duties and responsibilities as assigned. #
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.
CV Data Abstractor
Central Florida Regional Hospital, a 221-bed acute care hospital and Level II trauma center, serves the communities of Seminole and west Volusia counties. The hospital provides the only full-service cardiovascular program in Seminole and west Volusia, including open heart surgery, interventional cardiology, electrophysiology, cardiac rehabilitation and comprehensive diagnostic services. Other specialized services include orthopedic and spine care, robotic surgery, wound care, acute inpatient medical rehabilitation, complete imaging services and The Baby Suites. Central Florida Regional Hospital is located 3.6 miles east of I-4 between S.R. 46 and Highway 17-92 in Sanford.
POSITION SUMMARY: The CV Data Abstractor collects and analyzes data related to case management, performance improvement, and outcomes management. Prepares and maintains daily, weekly, and monthly statistical reports, operational and coordination functions, under the direction and supervision of the Director.
Associates degree in health related field required. Bachelor's degree in health related field preferred.
At least five (5) years recent data collection experience in one or more of the following areas; patient care, education, medical records, or patient safety required.
At least three (3) years working in Cardiovascular Surgery or Cardiovascular Cath Lab required.
Previous training in software data analyst functions including Word, Excel, Access, Power Point, Publisher, CHOIS, HPF, and Meditech required.
SKILLS, KNOWLEDGE & ABILITIES:
Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, ability to follow verbal instructions, PC skills, ability to multi-task, capable of daily problem-solving complex issues.
An EEO/AA Employer M/F/V/D
Abstractor Coordinator Regional
The Abstractor Coordinator Regional for West Non-Hospital Facilities abstracts west non-hospital establishes and maintains contact with Western, KY non-hospital facilities in order to collect and abstract information for cancer patients. Send out melanoma reporting forms and abstract incoming melanoma cases from non-hospital facilities.
Work with electronic pathology reporting system. Assist with research and special studies. Travel as necessary.
IEBC – Internal Employee Being Considered
Skills / Knowledge / Abilities
Microsoft Office Suite
Does this position have supervisory responsibilities? No Preferred Education/Experience
Bachelor's Degree with 1-2 years of related experience
Deadline to Apply 03/27/2019 University Community of Inclusion
The University of Kentucky is committed to a diverse and inclusive workforce by ensuring all our students, faculty, and staff work in an environment of openness and acceptance. We strive to foster a community where people of all backgrounds, identities, and perspectives can feel secure and welcome.
We also value the well-being of each of our employees and are dedicated to creating a healthy place to work, learn and live. In the interest of maintaining a safe and healthy environment for our students, employees, patients and visitors the University of Kentucky is a Tobacco & Drug Free campus.
As an Equal Opportunity Employer, we strongly encourage veterans, individuals with disabilities, women, and all minorities to consider our employment opportunities.
Any candidate offered a position may be required to pass pre-employment screenings as mandated by University of Kentucky Human Resources. These screenings may include a national background check and/or drug screen.
Ambulatory Abstractor (Lpn Or RN)
The Licensed Practical Nurse (LPN) or Registered Nurse (RN) for this position is will be traveling to multiple Ambulatory sites within Northwell Health's territory from Westchester to Suffolk County, Long Island and throughout the 5 boroughs. The Licensed Practice Nurse (LPN) or Registered Nurse (RN) for this role should be very flexible in regards to travel.
Locates specified clinical data for abstraction from various forms of medical records through intensive medical record review. Abstracts clinical information and inputs it into the electronic medical record.
Enters patient data into electronic health record and/or make corrections to information entered.
Responds to inquiries regarding data.
Ensures a high degree of accuracy of information entered.
Works with Practice physicians and clinical staff to set abstraction appointments, pulls charts according to the protocol and arranges for all necessary tools to conduct abstractions.
Represents PAANS Transformation Team and member's interest in supporting physicians to improve AEHR adoption and use.
Provides accurate and prompt post-assessment findings to the Practice abstracting project lead and to PAANS HIM.
Aggregates summary data, tracks routine statistics, conducts analysis and completes standard reports.
Carries out routine correspondence.
Performs related duties, as required.
High School Diploma or equivalent, required. Graduate from an accredited School of Practical Nursing or Nursing, required.
Current license to practice as a Licensed Practical Nurse (LPN) or Registered Professional Nurse (RN) in New York State, required.
Willingness to travel to multiples sites, highly desirable.
NYS Driver License, highly desirable.
Previous experience with medical records and/or abstracting experience, preferred.
Strong organizational skills, required. Knowledge of general office procedures and Microsoft Office.
Excellent written and oral communication and interpersonal skills, required.
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