Job Description

Job Title: Lead Medical Records Abstractor - Greentree
Job ID: 56484217
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Department: 55153 ZCMS1 PIMA Greentree
Location: 969 Greentree Road, Pittsburgh PA 15220


Assist Abstracting/Scanning manager with the day to day responsibilities of the abstracting team. Conduct a thorough review of the outpatient medical record, maintained by hospital based clinics and/or physician offices, for the purpose of abstracting the defined minimal data set into the EpicCare eRecord system with focus on the ePrescribing application.

  • Demonstrate a service-oriented approach to 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 make patient care and/or departmental service the first priority.
  • Assist in the development of abstracting policies, procedures, system demonstrations and training materials.
  • Interact directly with physicians and office staff to track these missing records and resolve data abstracting/data entry issues.
  • Assist manager with scheduling of abstracting staff at various physician/clinic locations ensuring appropriate coverage at all times.
  • Assist manager with abstractor timekeeping.
  • Perform a thorough review of the documentation within the outpatient medical record to enable accurate and active medication assignment and patient information in the eRecord application by understanding disease processes and clinical interpretation of medications administered during an outpatient visit.
  • Prepare daily abstracting productivity statistics and present this information to the Data Abstracting Manager on a weekly basis. Maintain a productivity level as specified in predefined performance standards and established accuracy rates.
  • Actively train and assist clinic/physician office staff and other abstractors in regards to abstracting the essential patient medical data set into the eRecord.
  • Assist in training in orientation of new abstractors and provides appropriate feedback.
  • Assist manager with performing quality assurance studies.
  • Review completed abstracts on a daily basis for overall accuracy and reports any problems to the Data.
  • Work directly with abstractors to answer questions to assist them in their abstracting efforts ensuring data integrity in the eRecord.
  • Attend eRecord training classes as assigned by management.
  • Coordinate missing chart report for abstracting purposes for follow up to obtain records that were initially unavailable.
  • Interact with and contact other clinical and physician office resources, to clarify medical record documentation as necessary.
  • Provide input to manager on annual performance appraisals.
  • Utilization of multiple software systems to ensure all appropriate essential patient medical data is abstracted in the EpicCare system.
  • Monitor 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.


  • Knowledge of medical record format and content of patient records.3 years of experience.
  • Ability to review records read physician documentation and verifies patient identification.
  • Strong command of medical terminology and understanding of medical abbreviations, diagnosis information and prescription drugs.
  • Strong computer skills. 
  • Detail oriented and possess a high degree of concentration to assure accurate data abstraction.
  • Ability to perform job responsibilities and make decisions without daily direct supervision.
  • Ability to research prescription drugs commonly found in patient charts.
  • Knowledge of terminal digit numbering and filing systems.
  • Ability to identify medical record forms, standard and nonstandard, and their appropriateness for inclusion in the eRecord. 
  • Ability to travel within a 2 to 3 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 eRecord application.
  • Interact tactfully and professionally with clinic/physician/project staff and management.
  • Excellent organizational skills, written/verbal communication skills, interpersonal skills, conflict resolution skills and problem solving skills.
  • Capable of managing multiple demands and working a flexible schedule as the job demands.

Licensure, Certifications, and Clearances:
RHIA, RHIT, RN or LPN preferred.

UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $16.72 to $26.54 / hour

Union Position: No

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