Job Summary
Abstracts demographic physician and patient information from patients medical records
Responsibilities
Data Collection: Gather and extract relevant medical data from multiple external sources including hospitals clinics and laboratory systems (Etc. to ensure comprehensive information for record completion. Data Input: Accurately input collected data into specific departmental software ensuring compliance with established protocols and standards. Quality Assurance: Review and verify the accuracy and completeness of the data entered into the departmental software identifying and correcting any discrepancies or errors. Collaboration: Work closely with healthcare providers and other stakeholders to facilitate data retrieval and clarify any ambiguities in medical records. Reporting: Generate and maintain reports on data collection progress and quality metrics to assist in ongoing improvement initiatives. Regulatory Compliance: Stay updated on relevant guidelines and best practices ensuring that all data handling and reporting meet regulatory requirements. Training and Support: Train new team members on data abstraction techniques and specific departmental software. Continuous Improvement: Participate in team meetings to discuss challenges share best practices and contribute to process improvement initiatives. This role is essential for ensuring highquality data collection and ma Work Environment and Level of Frequency typically required Nearly Continuously: Office environment. Physical Requirements and Level of Frequency that may be required Nearly Continuously: Sitting hearing listening talking. Often: Repetitive hand motion (such as typing) walking. Seldom: Bending reaching overhead.
Minimum Qualifications
Two years of coding experience using ICD 9CM or equivalency (one year of college education in a medical related field can be substituted for two years of related work experience). Demonstrated knowledge of medical terminology anatomy and physiology; and a basic knowledge of medical procedures and disease states/processes required. Computer literacy and demonstrated human relations and effective communication skills are also required. For some assignments additional coding experience using ICD 9CM a Certified Coding Specialist certificate or Registered Health Information Technician Credential is required. The incumbent is expected to enroll in continuing education courses to maintain certification. RHIA CCS or CPC certification is preferred. The Registered Health Information Technician certificate requires an Associates degree. A Registered Health Information Administrator certificate requires a Bachelors degree. This position is patientsensitive and must fulfill all associated requirements. We protect our patients coworkers and community by requiring all patientsensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.