Overview

This position works independently and abstracts a large volume of clinical case records within published deadlines for continuous reporting to internal and external quality and/or patient safety initiatives including but not limited to CommonSpirit Health, Catholic Health Initiatives (CHI), Dignity Health, Centers for Medicare and Medicaid (CMS), The Joint Commission (TJC) and other entities as required. The work involves managing the overall record retrieval process for abstracting required data, collecting numerous complex data elements from individual patient records, entering data into the applicable database while ensuring the integrity and timeliness of the electronic data transmitted to the established national database or entity. Abstractor, Clinical License are required to understand complex data specifications and methodologies underlying initiatives and must possess a significant understanding of the care processes and related documentation and coding processes for each of the clinical focus areas worked on.

Responsibilities

A remote assignment is available for an experienced Abstractor

Accurate, timely data abstraction for support of the CMS Hospital Inpatient and Outpatient Quality Reporting Program measures, TJC Core Measures, Get with the Guidelines, and/or other Clinical Quality and Patient Safety measuresKeeping constantly abreast of changes in data definitions and measure specifications. Maintains current knowledge of regulatory changes pertaining to quality performance improvement activities and reporting requirements.Apply all concepts of the nursing and other care processes, such as identification of disease, facilitation of healing, health promotion, illness presentation and patient care delivery to each task and patient reviewInforms hospital staff of variances as appropriate and updates supervisor/interested parties when significant trends appear in the data. Identification of potentially non-compliant cases requiring additional review. Proactively identifying risks to success with in focus areas being measured and communicating to appropriate personnel Interaction and detailed review of abstracted data with Clinical Programs, Quality Management, Patient Safety, etc.Collaboration with quality improvement team members and other key stakeholders in data accuracy and improvement efforts. Serving as an expert resource for key stakeholders
Qualifications
Licensed Registered Nurse (BSN preferred), Licensed Clinical Pharmacist, or other Licensed Clinical Staff able to perform medical and/or surgical Registry AbstractionDemonstrated clinical experience related to a wide variety of patient populations and care delivery modelsKnowledge of clinical practices, care processes, and proceduresSpecialized knowledge of Medical Records and Health Information Management practices and documentation, including familiarity with patient charts, disease classification and codingCompetency with extraction of information from health records, organization and management of information, and analysis of informationExperience with data abstractionKnowledge of Joint Commission Core Measures and CMS Hospital Inpatient and Outpatient Quality Reporting Program