Responsible for medical record abstraction and data entry functions to assist with coding function. Maintains current knowledge of regulatory changes (AHA Coding Guidelines, PHC4 and UB04) with respect to abstracting data elements. The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered a detailed description of all the work requirements that may be inherent in the position.
JOB DUTIES AND RESPONSIBILITIES:
Maintains current, up-to-date knowledge of data abstracting guidelines and Coding Department guidelines for data entry.
Achieves 95% or greater data abstracting quality.
Achieves data abstraction daily productivity standard of 75 inpatient/observation charts per day or greater.
Assists with training new employees.
Works with the Business Office, Registration and IT/EPIC for corrections.
Communicates immediately concerns/issues requiring immediate attention to the Director, Network Coding Services.
Ability to communicate effectively and tactfully to the Coding Staff, Medical Staff and other internal and external customers.
Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
Demonstrates/models the Network’s Service Excellence Standards of Performance in interaction with all customers.
Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.
Complies with Network and departmental policies regarding attendance and dress code.
Demonstrates competency in the assessment, range or treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting for up to 8 hours per day, 3-4 hours at a time. Repetitive arm/finger use for retrieving/viewing computerized patient medical record and abstracting of patient information. Extended periods of vision use for reviewing computerized patient record, abstracting of patient information, approximately 8 hours per day, 3-4 hours at a time. Hearing as it relates to normal conversation. Seeing as it relates to general vision, near vision, peripheral vision and visual monotony. Occasionally may conduct speaking engagements, utilizing speech as it relates to general speaking tone. Occasionally may be required to use upper extremities to lift up to 10 lbs., stoop, bend or reach to retrieve resource materials and/of paper records in accordance with downtime policy.
EDUCATION:
Associate Degree in Health Information Technology program preferred. Will consider Associate Degree in a health-related field. Medical Terminology course necessary.
TRAINING AND EXPERIENCE:
Minimum 1 year experience in data abstraction position or an equivalent medical information position, preferably in an acute care setting, teaching hospital environment.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!