Job Description
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 Apply tot his job