About the position
Responsibilities
• Receives, collects, sorts, prepares and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures.
• Sort and measure incoming and remaining scanning to accurately track volumes and turn-around times in the system-wide database.
• Analyzes non-interfaced patient laboratory reports to ensure patient identifiers and compliance with all applicable regulations including Wisconsin Collaborative for Healthcare Quality (WCHQ) and Clinical Laboratory Improvement Amendments (CLIA) guidelines.
• Utilizes optical character recognition software to electronically and or manually enter appropriate data into the EHR.
• Identifies, creates or releases the appropriate laboratory tests by applying knowledge of medical terminology and laboratory nomenclature.
• Selects the correct order templates, discretely enters and validate individual components, comments, footnotes, performing laboratory name and address, collection date and time, units of measure, reference ranges, abbreviations and symbols.
• Discretely abstracts and imports laboratory results and other clinical documentation into the EHR.
• Records normal and abnormal findings.
• Ensures laboratory values are accurately entered and flagged to promptly alert patients and clinicians regarding normal and abnormal results.
• Locates or creates the appropriate patient, encounter, and/or order.
• Correctly paginates and classifies documentation to the appropriate document type and description.
• For sensitive laboratory information, ensures appropriate security levels and protection of information according to HIPAA rules.
• Readily adapts to new and/or evolving laboratory tests, parameters, reference ranges, and regulations.
• Validates all data points and laboratory codes, and uses critical thinking skills to identify and investigate questionable information and troubleshoot issues.
• Escalates issues and reports patterns of concern to leadership timely.
• Communicates with patient care and external performing laboratories via phone, email, fax, Epic In Basket, and other methods to provide education, STAT laboratory data entry services, and to obtain CLIA-compliant reports.
• Performs quality assurance of scanned documentation to ensure clinical documentation is scanned to the correct patient, encounter, document type, and orderable in a timely manner according to Health Information Management policy.
• Verifies the electronic information against the paper document to validate accuracy, clarity, and legibility.
• Completes timely error correction or notification process; including re-resulting or deleting documentation as needed.
• Ensure secure retention and destruction of electronic and physical PHI in accordance with applicable regulations and policies.
• Operates all office equipment, performs daily routine maintenance of equipment and reports any equipment malfunction or poor image quality to the appropriate personnel.
Requirements
• High School Graduate.
• Typically requires 2 years of experience in health information or in providing laboratory assistance.
• Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, Extract LabDE, OnBase, Microsoft 365 and legacy archives.
• High attention to detail and accuracy with frequent interruptions.
• Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints.
• Ability to work independently (onsite and/or remotely) and make decisions with minimal supervision while maintaining quality and productivity standards.
• Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve.
• Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success.
• Ability to proficiently operate all equipment necessary to do the job: fax, multi-phone line, scanner, copy machine, etc.
• Must be able to sit, stand, walk to perform rounds in time allotted, squat, twist/rotate, bend and reach for prolonged periods of time in order to complete required word processing, filing, photocopying, and distribution of materials and other related functions.
• Requires team member to walk a moderate/significant distance throughout medical center to retrieve records.
• May require the ability to push/pull a records cart.
• Must be able to sit and stand majority of the workday.
• Must be able to reach above head, bend, and stoop.
• Must be able to lift and carry up to 20 lbs. frequently.
• Must be able to perform repetitive motions using hands, wrists and /or fingers.
• Operates all equipment necessary to perform the job.
Benefits
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program
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