Job Description

The Lead Abstraction Specialist supports the chart abstractor team and the Primary Care Clinic team. Reviews, analyzes, and summarizes pertinent clinical data from a patient’s medical record. Verifies, inputs, and updates the health maintenance for patients in computer system to enhance continuity of care between patient care providers. The Lead Abstraction Specialist also coordinates training for chart abstractors, attends quality meetings, and facilitates care gap notifications.

Responsibilities/Duties:

• Participates in the monthly Primary Care quality meetings. Contributes to planning and improvement initiatives related to abstraction and metric reporting.
• Attends the monthly Provider meetings at the request of the Clinic Manager or Clinic Medical Director.
• Trains, mentors and supports other abstractors, ensuring consistency and accuracy. Develops training material as appropriate.
• Completes regular rounding with other abstractors to support team cohesion.
• Facilitates the care gap notifications via MyChart or printed letters.
• Coordinates and prioritizes the team’s workload to optimize patient care.
• Oversees clinical chart abstraction and ensures quality and timely results.
• Works closely with IS to trouble shoot errors in care gaps/health maintenance.
• Works closely with the Quality Department, specifically the Data Analyst.
• Acts a liaison interdepartmentally to coordinate and complete health maintenance projects.
• Abstracts vital medical information into the computer system.
• Updates vital medical information into the computer system.
• Summarizes medical information to be abstracted into computer system.
• Works collaboratively with Clinic Operations Manager, Clinic Medical Director and HIM.
• Understands and maintains confidentiality standards in compliance with State and Federal regulation, including HIPAA.
• Meets acceptable standard of attendance and promptness.
• Uses supplies and other hospital resources appropriately.
• Stays current with employee health requirements.
• Completes in-service training on an annual basis.
• Accepts responsibility for his/her own continuing education and identifies and pursues appropriate goals related to learning.
• Demonstrates safety practices in the performance of his/her job.
• Demonstrates awareness of compliance program and hotline.
• Complies with all rules, regulations, laws, policies, procedures, and standards within the code of conduct.
• Can describe appropriate reporting procedures for any compliance failure.
• Shares knowledge freely and keeps other staff updated.
• Communicates appropriate information freely to facilitate support department goals.
• Offers and accepts feedback in an honest, open, and supportive manner.
• At times work onsite to include education, meetings, etc.
• Reviews communications sent from health information staff regarding patient medical records.
• Analyzes and understands medical information that is vital to providing quality patient care.
• Prepares in advance key information that is needed for continuity of patient care.
• Communicates to clinic staff important information needed for patient care.
• Works collaboratively with all clinic and health information staff.
• Assists all staff and processes in identifying work flow improvement strategies.
• Other duties as assigned by clinic manager.

Education/Experience:

• High School diploma or equivalent.

• Knowledge of medical terminology required.

• Experience in chart abstracting required.
• Experience with Epic is required.
• Strong attention to detail.