Job Description
Job Summary The Clinical Abstractor is responsible for reviewing and analyzing medical records to extract key data and information in compliance with regulatory reporting standards. Clinical abstractors have a strong background in healthcare, excellent analytical skills, strong knowledge of medical terminology and healthcare concepts, and proficiency with electronic medical record systems and clinical documentation software. They maintain up-to-date knowledge of healthcare regulations and standards and can manage and prioritize workload to meet deadlines. The clinical abstractor will perform data abstraction and inter-rater reliability testing for all Pipeline Health System hospitals.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
Essential Functions - Conducts medical record reviews and abstraction for designated core measure data and/or registry.
- Ensures complete data collection EMR and entry into an electronic database.
- Timely data abstraction and submission per regulatory requirements.
- Participates in the analysis and evaluation of collected data.
- Maintains accuracy, integrity and reliability of the abstracted data.
- Current knowledge of rules, regulations, policies, and procedures related to third party payers, such as The Joint Commission (TJC), Center for Medicaid and Medicare Services (CMS), and other state and federal regulatory agencies.
- Responsible for abstracting all clinical data requested of management and physicians from any electronic data collection system with the interpretation and presentation or conclusions via chart, graph, or spreadsheet format.
- Assumes responsibility and accountability for personal professional growth and development.
- Manages workload effectively.
- Understands and maintains awareness of fiscal responsibility by utilizing time and resources appropriately.
- Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
- Uses AIDET in interactions with patients and family members.
- Acts with a sense of urgency when performing tasks.
- Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
- Reports on any equipment and or environmental issues for repair.
- Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
- Speaks up to stop the line and escalates potential safety events if necessary.
- Completes and attends monthly training assigned.
- Other duties as assigned.
Behavioral Standards - Exhibits customer and service-oriented behaviors in everyday work interactions.
- Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.
Communication/Knowledge - Provides accurate and timely written and verbal communication of information in a manner that is understood by all.
- Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
- Proficient in the utilization of Microsoft Office/Outlook, Word, Excel, and electronic health records.
Collaboration/Teamwork - Contribute toward effective, positive working relationships with internal and external colleagues.
- Demonstrate cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.
Qualifications/Experience - A minimum of three (3) years of work experience in an acute care facility and demonstrated learned and working knowledge of general hospital operations.
Job Tags
Part time, Work experience placement, Work at office, Day shift,