CLINICAL DATA ABSTRACTOR

Job Description

Reporting to the Data Manager, Clinical Registries and Core Measures, the Clinical Data Abstractor supports the coordination of ongoing performance improvement activities across both UMMC campuses through expert clinical data retrieval and analysis. Serves as a resource for support departments to assist with identification and resolution of quality and/or patient safety issues as well as regulatory compliance.

This position description indicates in general the nature and levels of work, knowledge, skills, abilities and other essential functions expected of an incumbent. It is not an exhaustive comprehensive listing of activities, duties or responsibilities required of an incumbent. An incumbent may be asked to perform other duties as required.

Principal Duties

* Perform chart review and abstraction as needed to assist with data analysis and to meet regulatory requirements across both UMMC campuses.
* Support data needs for expanding regulatory quality and performance reporting requirements.
* Collaborate with system clinical analytics and Decision Support to facilitate enhanced use of the electronic abstraction platform by providing feedback and identifying enhancements or additional functionality for local and system
* Aid users on the enhancement of data collection and abstraction processes by automating data collection and reports when possible. Solicit user feedback on data needs and workflow processes, and make appropriate changes that will increase end users' efficiencies.
* Serve as resource to department, hospital staff, and new employees for specific hospital systems by providing guidance on data abstraction needs, including developing educational materials.
* Prepare and present clinical data from various systems for decision making and support of performance improvement initiatives.
* Consult with administrative, medical, and hospital staff and provide recommendations to quality team regarding data management and development of metrics and tools to support ongoing quality and performance improvement projects.
* Collaborate with departments and/or teams by providing information and recommendations for identifying benchmarks and outcomes/indicators which can be monitored for quality and performance improvement

Primary Responsibilities

1. Coordinate and work with others on the development of dashboards and quality/ performance reports by preparing and/or coordinating preparation of reports with others.

2. Assist in guiding improvement efforts by identifying and collecting appropriate information.

3. Communicate accurate information in a timely manner concerning data abstraction issues to leaders and/or other health care professionals.

4. Ensure accurate data collection from multiple sources, electronic records and other computerized systems.

Customer Service

* Greets customers in courteous, friendly, respectful and professional manner at all times, including maintaining eye contact when appropriate.
* Follows communication protocols to both internal and external customers.
* Responds promptly and appropriately to customer questions/concerns/complaints and attempts immediate resolution.
* Keeps customer's information confidential, including public places such as elevators or the cafeteria.
* Provides assistance and offers help immediately, including finding someone else to meet the request, if unable to do so him/herself. Introduce other staff to customers when a hand-off occurs and explain that the person will provide excellent service.
* Demonstrates commitment to excellent service recovery when a customer's expectations have not been met

Commitment to Co-Workers:

* Offers assistance to colleagues and other departments when needed.
* Takes responsibility for solving problems regardless of origin; completes assignments, and respects deadlines.
* Resolves conflict directly with colleagues and seeks assistance from others if the issue cannot be resolved. Refrains from criticism in public.
* Mindful and respectful of others' time and schedules. Attends meetings on time and communicates any absences.
* Provides co-workers with a status report for continuity of workflow when planning to be out of the office, off the unit, or away from the department

Communication Etiquette:

1. Respectful, courteous and professional in all forms of communication and follows facility's service communication protocol in all interactions.

2. Does not text or use e-mail during meetings (except for exigent or emergency situations).

3. Maintains an appropriate voicemail message and when away from the office has an out-of-office email message that is brief, current, and includes name and department and offers the caller options if possible.

4. Returns email and voicemail messages promptly.

5. Always mindful of voice and language in public.

Self-Management:

* Reports to work appropriately groomed and in compliance with the Hospital's dress code. Wears identification badge at all times at chest level and facing outwards so identification is clearly visible.
* Complete all assignments within deadlines or negotiates alternative actions and time frames in order to achieve desired outcomes.
* Completes mandatory, annual education and competency requirements.
* Follows UMMC safety and employee health standards.
* Demonstrates responsibility for personal growth, development and professional knowledge and competency.
* Adhere to all UMMC and department policies and procedures, including Code of Conduct and professional behavior standards. Does not exceed Hospital guidelines in reference to attendance, punctuality, and use of sick and unplanned absences. Provides notification of absences, lateness and vacation requests according to department guidelines. Respects length of time for lunch and break times.
* Reviews, signs, and adheres to UMMC and/or departmental confidentiality statement.

Company Description

Renowned as the academic flagship of the University of Maryland Medical System, our Magnet-designated facility is a nationally recognized, academic medical center with opportunities across the continuum of care. Come join UMMC and discover the atmosphere where talents and ideas come together to enhance patient care and advance the science of nursing. Located in downtown Baltimore near the Inner Harbor and Camden Yards, you won't find a more vibrant place to work

Qualifications

Education and Experience

* Bachelor's degree in nursing required, Master's degree preferred.
* Current Maryland Nursing license
* Five to seven years of experience as a clinical nurse or clinical data abstractor required. More than seven (7) years preferred.

Knowledge, Skills and Abilities

* Microsoft Office Skill level: Word - intermediate; Excel - intermediate; and PowerPoint - basic
* Working knowledge of medical coding
* Basic knowledge and working experience with medical terminology
* Knowledge of Inpatient and Outpatient Core Measures Abstracting
* Knowlege and experience with Core Measures databases
* Effective oral/written communication skills
* Ability to work independently
* Ability to resolve problems through well-developed processes and procedures and requires basic scientific, mathematical or technical level training.

Additional Information

Position may be fully remote

---