University of Rochester Abstraction Specialist in Rochester, New York


Time as Reported Grade 007 Primary Care Administration


Position Summary:

The medical records abstraction specialist is responsible for abstracting patient data from paper or electronic medical charts and entering abstracted data into eRecord. Provides an essential service in transferring patient information from one format of a patient’s medical record to another. The ideal candidate is a highly organized, professional, and self-directed individual.

Essential Duties:

Working collaboratively, the Medical Records Abstraction Specialist will:

  • Hold multiple meetings with physicians and staff to review current chart organization and storage to become familiar with the chart lay-out of critical medical history to prepare to parse out for proper medical record abstraction activity.
  • Interpret medical terminology to abstract health information from patients’ paper or electronic medical charts according to a set standard and protocol; Core elements of health detail includes the patient history or problem list, allergy history, last colonoscopy, last mammogram, last A1C and LDL results and immunization history.
  • Enter the abstracted and interpreted health care data including medical terminology, diagnosis codes (ICD-9) and medical codes into the appropriate sections within eRecord.
  • Represent Primary Care Administration and its members’ interest in supporting physicians.
  • Aggregate summary data, track routine statistics, conduct analysis, complete standard reports including quality control checks.
  • Any and other tasks as assigned.


2 years of post High School courses with emphasis in Data Processing or Medical Terminology, accreditation as Medical Record Technician, 1-2 years related work experience; or equivalent combination of education and experience. Associate’s or Bachelor’s degree preferred. Prior experience as medical records abstractor may substitute for education qualification.

The ideal candidate for this position is highly organized, self-motivated and self-disciplined in order to work independently. Must be able to set priorities, meet deadlines, communicate proactively and follow up with minimal direction. High standards of professional ethics, able to maintain strict confidence of private information, and respectful of others. Experience with medical records preferred. Abstracting experience preferred. Knowledge of medical terminology, standard medical abbreviations, and pharmacy terms sufficient to identify proper location of specific health information. Strong data analytical skills, organizational, facilitation, and project management skills required. Outstanding written and oral communication and interpersonal skills. Knowledge of general office procedures.

EOE Minorities/Females/Protected Veterans/Disabled

Job Title: Abstraction Specialist

Location: Strong Memorial Hospital

Job ID: 204367

Regular/Temporary: Regular

Full/Part Time: TAR