Medical Records Abstractor (775399)

MANDATORY TRAINING

The Medical Record Abstractor is responsible for completing all DOH-mandated training that applies to contracted personnel.

Description of Duties

This position is under the direct supervision of an Epidemiologist. The Medical Record Abstractor communicates and collaborates on a regular basis with the supervisor, Infectious Disease Epidemiology program lead, and other team members.

The Medical Record Abstractor shall correspond with Health Information Management staff in hospitals across Pennsylvania to identify potential cases of hepatitis C in pregnant women and infants, request medical records for review, and coordinate remote access or in-hospital visits to perform medical record abstraction.

The Medical Record Abstractor shall monitor the progression of assigned work and respond to and mitigate barriers to completing the assigned work on time.

The Medical Record Abstractor shall provide updates to supervisor about the progression of the assigned work.

The Medical Record Abstractor shall provide a comprehensive review of hospital discharge summaries, diagnostic indices, and other documentation within medical records to identify and confirm disease diagnoses.

The Medical Record Abstractor will abstract demographic diagnostic, clinical, epidemiologic, and administrative data from medical records into a computerized case record following defined procedures. The Abstractor will also code disease diagnoses based on ICD-10 medical coding system.

The Medical Record Abstractor shall act as a liaison between the Surveillance Program and area facilities, working toward the establishment of remote access to medical records.

The Medical Record Abstractor will generate and compile reports as necessary and in coordination with supervisor and team members.

DRESS CODE

ID must always be worn and must be clearly visible and readable (other than teleworking). The Healthcare Epidemiologist shall dress in a manner that conveys professionalism; typically, in a “business casual” style.

ORAL AND WRITTEN COMMUNICATIONS

· Interacts with team members and stakeholders using professional communication skills.

· Provides clear, concise, and comprehensive written work.

· Uses Skype and Outlook to facilitate meetings.

· Maintains healthcare facility confidentiality.

· Interacts with colleagues in a cooperative manner to develop effective working relationships.

· Reports problems accurately using the chain of command.

· Keeps conversations free from discriminatory, abusive or sexually harassing comments.

· Prepares and submits thorough and accurate reports in a timely manner.

· Submits incident reports and work-related injury paperwork in a timely manner.

CRITICAL THINKING

· Prioritizes work tasks to be accomplished.

· Recognizes/anticipates needs of contracting organization, colleagues, stakeholders, and nursing homes.

· Identifies recurring problems and barriers.

· Implements practical solutions to mitigate problems and overcome barriers.

· Organizes files to easily access information.

· Monitors assigned work performance to easily report on progress.

· Abstracts medical record information efficiently and accurately.

· Coordinates with multiple organizations to accomplish the same goals.

· Seek guidance and permission when appropriate.

PROFESSIONAL CONDUCT

· Always demonstrates professional conduct.

· Demonstrates ethical behavior in the workplace.

· Maintains a non-discriminatory work environment.

· Abides by the Governor’s Code of Conduct and DOH Personnel Regulations, policies and procedures, and Bureau of Epidemiology policies and procedures.

· Adheres to scheduled work hours or informs supervisor of changes to schedule.

· Maintains patient and hospital confidentiality.

· Submits time sheets and travel expense reports in a timely manner.

About Us:

TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.

TulaRay is proud to be an affirmative action employer and is committed to providing equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you have a disability or special need that requires accommodation, please let us know by visiting our website at tularay.com