Unit Secretary Abstractor

Candidate will be responsible for assisting physicians and clinic departments by providing clerical/technical assistance to maintain accurate electronic health data. Will work in a team environment and follow established routines for EHR data entry and communications. Ideal candidate demonstrates high-level of customer service skills, is detail oriented and efficient in the entry of data into health information systems via keyboard and mouse.

• Obtain medical records and imaging on patients.
• Responsible for initial entry of patient data in EHR.
• Updates EHR with incoming patient records from transferring care providers.
• Maintains appropriate records, reconciling information with external and internal sources if necessary.
• Keeps work area neat, clean and safe.
• Cooperates with other personnel to maintain good employee and public relations.
• Informs supervisor or clinic manager of concerns and problems.
• Assist with other EHR assignments as needed.
• Complies with HIPAA regulations.
• Participates in quality measures.
• Willing to accept additional assignments.
• Demonstrates a customer-service, high satisfaction approach to work with providers and patients while entering data into the EHR.
• Abstracts records, meeting a minimum abstraction rate of 20 charts per day.
• Abstracts records consistently according to departmental standards, following the listed identified needs:
  • Allergies
  • Medications – as directed by Director of Clinic Operations and Nursing
  • Medical History
  • Surgical History
  • Family History
  • Immunizations
  • Health Management Screen
  • Diagnostics
  • Quality Information

Education/Experience:

• Requires High School Degree or GED.
• Requires good interpersonal and communication skills (written and verbal) to effectively interact with physicians, patients, families, and clinic staff.
• Requires 6 months of prior abstracting experience.
• Knowledge of technical medical procedures, preferred.
• Prior medical terminology education, preferred.