Medical Records Abstractor

JOB SUMMARY: The primary purpose of this position is to ensure the accuracy, completeness, and integrity of the electronic medical record (EMR). This role is responsible for coordinating information between providers and internal departments to ensure patient documentation is thorough and up to date and abstracting relevant information from outside medical records into the EMR. The position requires accurate transcription of provider dictation, routing completed documentation to appropriate providers, and troubleshooting documentation or record issues as they arise. The ideal candidate is detail-oriented, organized, and able to work both independently and collaboratively. This position supports clinic operations during scheduled clinic hours and may include a combination of remote and in-clinic responsibilities.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Scan/import medical information into charts according to clinic guidelines.
2. Collect paper documentation, ensure accurate scanning to the EMR
3. Assist with quality improvement initiatives by organizing and maintaining patient data.
4. Review and update Power of Attorney, Guardianship, and other legal documentation within the EMR
5. Collaborate with providers and clinical assistants to support thorough and accurate patient documentation.
6. Abstract predetermined clinical information from outside medical records into the electronic health record.
7. Respond to phone calls, emails, and/or fax requests from patients, medical facilities, and staff regarding release or transfer of records within two business days.
8. Manage communication and requests submitted through Medical Records EMR message pools.
9. Provide support with scanning, document management, and other administrative tasks as needed.
10. Maintain strict patient confidentiality and comply with all HIPAA laws, regulations, and clinic policies
11. Demonstrate excellent customer services skills over the phone or in person.
12. Perform other duties as assigned.

SUPPLEMENTAL DUTIES AND RESPONSIBILITIES:

1. Maintain confidentiality of all information acquired through employment with the Clinic, including both medical and business information.
2. Establish and maintain positive working relationships and open communication with patients, providers, internal personnel and personnel from other facilities.
3. Adhere to Clinic and departmental policies, procedures, and protocols.
4. Demonstrate a desire to continually learn and participate in looking for new ways to improve processes and procedures.
5. Notify Administration and coworkers of all service-related and/or employment related situations that appear unusual or emergent, as well as regularly required or directed information/communications.
6. Attend training sessions, in service, departmental & facility meetings.
7. Perform other duties & responsibilities as required or assigned.
8. Expected to abide by the ergonomic recommendations of this job description.
9. Adheres to the philosophy and provides comprehensive care according to a patient centered healthcare clinic

WORKING CONDITIONS:

1. Subject to constant interruptions, imposed deadlines, prioritized work and frequent problem-solving activities.
2. Standard office environment.

PHYSICAL DEMANDS:

1. Must possess sight/hearing senses, or use prosthetic devices that will enable these senses to function adequately.
2. Subject to lifting and carrying supplies averaging 25 lbs. (i.e. cartons of paper, medical supplies, office supplies, etc.).
3. Must have the body mobility to perform the following activities 6-8 hours per day: walking, standing twisting bending, kneeling squatting, reaching, repetitive flexing, repetitive rotation, reaching overhead, firm grasping, and sitting.

EDUCATION:

• Minimum: High School Diploma
• Desired: Some post secondary education and/or training in health care setting.

EXPERIENCE:

• Minimum: 1-2 years in a customer service role.
• Desired: 2 years' experience with medical records

KNOWLEDGE:

1. Medical terminology.
2. Ability to work independently with minimal instruction.
3. Proficient in basic computer operation, including Microsoft Office.
4. Proficient in operating accessory hardware including scanners, printers, copiers, and fax machines.
5. Can type a minimum of 40 wpm.
6. PowerChart and PWPM operation.