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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).
Job Responsibility
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.
Requirements
High school diploma or equivalent
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.
Nice to have
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
Minimum 1 year medical record experience
Proficient in the use of computer systems to include GroupWise, Microsoft Office, mainframes and the electronic medical record.