Clinical Data Abstractor - Main Performance Improvement - PRN

Job Description

To utilize established policies and procedures to perform concurrent and retrospective data abstraction, under the supervision of the manager. To ensure accuracy and quality of data collected, export data into the electronic data collection system, and review inaccuracies with the appropriate leadership teams.

Responsibilities

Conducts medical record reviews and abstraction for designated core measure data and / or registry. Ensures complete data collection (both paper and EMR) and entry into an electronic database. Participates in the analysis and evaluation of collected data. Functions as a resource in formulating action plans related to findings. Maintains accuracy, integrity, and reliability of the data to support the data base. As assigned, functions as support to medical staff committees (peer review), interdisciplinary QI / PI teams, and hospital departments by performing the following activities : 1. Collects appropriate quality performance data and clinical information for data bases. 2. Analyzes and evaluates data and clinical information to identify quality issues and trends.

Assumes responsibility of accurate data collection for specific reports and ensuring data distribution to the appropriate areas. Responsible for abstracting all clinical data requested of management and physicians from any electronic data collection system with the interpretation and presentation of conclusions via chart, graph, or spreadsheet format. Current knowledge of rules, regulations, policies, and procedures related to third party payers, The Joint Commission (TJC), CMS, and other regulatory agencies.

Acts as a resource and educator for multidisciplinary team members. Assumes responsibility and accountability for personal professional growth and development. Manages workload effectively. Understands and maintains awareness of fiscal responsibility by utilizing time and resources appropriately.

Qualifications

EDUCATION : Bachelor's Degree in a health-related field, health care management, or business management required, Master's Degree preferred. Registered Nurse from an accredited college of nursing with BSN degree preferred.

YEARS OF EXPERIENCE : A minimum of three (3) years of accreditation or health care management related experience or 3-5 years of acute care nursing is required. Master's Degree may supersede need for years of experience.

REQUIRED SKILLS AND KNOWLEDGE : The Performance Excellence (PE) data abstractor accurately abstracts required data. The PE data abstractor effectively communicates with peers, utilizes appropriate channels of communication, and maintains absolute confidentiality.