Clinical Data Abstractor

About the Role

This position is responsible for providing analytic support (data abstraction, analysis, investigation, reporting and follow-up) for clinical, administrative, and quality indicators from internal and external initiatives to improve patient care and clinical outcomes. Additionally, this position provides data and reports to support quality management, patient safety, performance improvement, and clinical documentation processes.

Responsibilities

• Gathers data via medical record chart review, database queries and reporting workbench reports.
• Integrates clinical background with registry specific abstraction principles to accurately determine inclusion and exclusion criteria for both diagnosis and procedural related codes for the process and outcomes measure databases which CCAD actively participates.
• Analyzes data against quality indicators using complex standards and protocols according to National and International clinical guidelines.
• Abstracts and validates metrics related to hospital accreditation, specialty certification and Department of Health regulatory requirements.
• Uses clinical knowledge to identify trends related to clinical outcomes.
• Uses clinical knowledge to determine appropriateness of results and ensures accuracy of clinical and administrative data queries.
• Develops reports in graphical format, using reporting systems, for review and distribution to various hospital or medical staff committees.
• Works closely with Clinical Registry Reporting Manager in validating abstraction of outcomes registry data.
• Provides data analysis for decision support in the Performance Improvement Process; clearly and succinctly communicates to PI Team and clinical stakeholders the rationale and analysis of abstracted data for the purposes of a Performance Improvement Project.
• Maintains content expert understanding of the definitions and algorithms for clinical registry, outcomes and quality and patient safety measures as changes are announced; ability to clearly communicate same to IT Team to facilitate in the development, testing and validation of electronic tools intended to electronically capture discrete data for data registry reporting and validation.
• Ability to clearly communicate with and educate staff in registry reporting changes and resultant impact on documentation practices.
• Assists with special projects as needed.
• Performs other duties as assigned.

Qualifications

• Nursing degree is required.
• Bachelor’s degree is required.
• Minimum of Associate degree is required.

Required Skills

• Minimum of two (2) years of clinical experience and working knowledge of general hospital operations, workflows and clinical documentation requirements.
• Minimum of one (1) year experience in a role requiring chart review, analysis of data from a medical record or other technical databases, manipulation, interpretation or routine reporting of data.
• Understands the design of healthcare documentation systems (Electronic Health Record, Cardiovascular Hemodynamic Systems, Registry Databases).
• Previous experience reporting to Clinical Reporting Registries (i.e. American College of Cardiology, Society of Thoracic Surgeons, National Surgical Quality Improvement Project), The Joint Commission, Center for Medicare and Medicaid Services, Agency for Healthcare Research and Quality, and Health Regulators required.
• Ability to express complex analytical and technical information to Executives or to Institute or Department leads.
• Proficient in the use of PCs, spreadsheets and other software applications.
• Strong oral and written communication skills.