Health Information Data Representative Lab

Milwaukee, United States

Major Responsibilities:

Navigates various electronic health record (EHR) and computer applications to perform the following job duties to support patient care, care management initiatives, revenue cycle, regulatory requirements and meaningful use. 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.

Licensure, Registration, and/or Certification Required:

None Required.

Education Required:

High School Graduate.

Experience Required:

Typically requires 2 years of experience in health information or in providing laboratory assistance.

Knowledge, Skills & Abilities Required:

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.

Physical Requirements and Working Conditions:

Exposed to normal office environment. May be exposed to dust.
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.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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