Abstractor - AHN Neuroscience Institute - AGH - FT

Job Title

Abstracts clinical data from medical records in accordance with regulatory and administrative reporting requirements, with a primary focus on the extraction from Epic, transformation within Microsoft Excel, and submission of structured workbooks to the American Spine Registry (ASR) portal. Additional quality improvement abstraction projects will occur from time to time for other conditions within the Neurosciences (Neurosurgery, Neurology, Pain Medicine).

Proficient skills in Microsoft Excel, including experience with basic formulas, tables, filters, analysis, and following data integrity processes.

Demonstrated ability to interpret clinical documentation, e.g. operative reports, and medical terminology

Strong problem-solving skills, with the ability to identify and resolve data discrepancies.

Abstracts clinical data from medical records in accordance with regulatory and administrative reporting requirements.

Abstracts key clinical findings accurately and in a timely manner and performs direct data entry for inclusion into an aggregate database to meet the requirements of the state, internal use, third party payer requirements and external quality improvement participation based on guidelines.

Performs system functions and report running as needed.

Participates in ongoing data quality studies to ensure an accurate database.

Performs other duties as assigned or required.

Minimum

• High school diploma or equivalent.

Preferred

• Associate's Degree.
• Successful completion of college-level courses in Anatomy & Physiology and Medical Terminology.
• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).
• Minimum 1 year abstracting experience preferred. Minimum 1 year medical record experience.
• Proficient in the use of computer systems to include GroupWise, Microsoft Office, mainframes and the electronic medical record.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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