Job Description

Job Title: Medical Records Abstractor
Job ID: 706082
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Cancer Centers
Department: ONCOL Admin Cancer Centers
Location: 5150 Centre Avenue, Pittsburgh PA 15232

Description

Purpose:
The UPMC CancerCenter is hiring a Medical Record Abstractor to join their team!  This role conducts a thorough review of the outpatient medical record, maintained by hospital-based clinics and/or physician offices, for the purpose of abstracting, scanning, and indexing specified key clinical data elements into the electronic medical records system.

This role requires 100% travel! It is Monday-Friday during daylight hours.  Sound like a fit for you?  Apply today!

Responsibilities:
  • 3 Extracts and enters defined data elements found in the patient physical chart into the electronic clinical systems.
  • Attends electronic clinical systems departmental meetings as required.
  • Coordinates missing chart report for abstracting purposes for follow up to obtain records that were initially unavailable. Interacts directly with physicians and office staff to track these missing records and resolve data abstracting/data entry issues.
  • Demonstrates a service-oriented approach to his/her position by conveying courtesy, respect, enthusiasm and a positive attitude in work situations, by showing initiative and offering assistance to other staff members and office personnel in the completion of the department's work, and by making patient care and/or departmental service the first priority.
  • Interacts and contacts other clinical resources, both internal and external as needed, to clarify medical record documentation as necessary.
  • Monitors and problem solves as necessary on issues such as invalid patient information in order to assure a complete and accurate abstract of the patient's paper chart.
  • Prepares daily abstracting and scanning productivity statistics and presents this information to the HIM Manager on a weekly basis. Maintains a productivity level as specified in predefined performance standards and established accuracy rate.
  • Preps, Scans, perform quality control and indexing of predefined documents from the patient record into the electronic clinical systems.
  • Responsible for performing a thorough review of the documentation within the outpatient medical record to enable accurate ICD-9-CM and CPT-4 code assignment in the electronic clinical system application by understanding disease processes and clinical interpretation of medications administered during an outpatient visit.
  • Reviews completed abstracts on a daily basis for overall accuracy and reports any problems to the HIM Manager.

Qualifications

  • High school with a minimum of one to two years of prior medical office, abstracting and/or coding experience in a hospital or ambulatory care setting required OR graduate of an approved, accredited health information management program, nursing or other clinical program. 
  • Preferred Job Requirements:  
    • Knowledge of medical record format and content of patient records 
    • Ability to review records, read physician documentation and verify patient identification 
    • Competent knowledge and understanding of anatomy/physiology, medical terminology, medical abbreviations and prescription drugs 
  • Strong computer skills 
  • Good verbal and written communication skills 
  • Detail oriented and possess a high degree of concentration to assure accurate data abstraction 
  • Able to perform job responsibilities and make decisions without daily direct supervision 
  • Ability to research different diagnoses, surgeries, and prescription drugs commonly found in patient charts
  • Ability to perform routine maintenance and adjust settings on the scanning equipment
  • Knowledge of terminal digit numbering and filing systems 
  • Ability to identify medical record forms, standard and nonstandard, and their appropriateness for inclusion in the electronic clinical systems
  • Must be able to travel within a two to three hour drive of Pittsburgh and work flexible hours (i.e. some evening and weekend hours may be necessary periodically) 
  • Maintain strict confidentiality of patient information and adhere to HIPAA regulations 
  • Ability to perform timely, high volume, tedious data review and entry into the electronic clinical system application
  • Must be able to interact tactfully and professionally with clinic/physician/project staff and management.

Licensure, Certifications, and Clearances:
Registered Health Information Associate (RHIA), Registered Health Information Technician (RHIT), Registered Nurse (RN) or Licensed Professional Nurse (LPN) preferred.

  • Act 34 Criminal Clearance
  • Basic Life Support

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $15.13 to $23.82

Union Position: No

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