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Clinical Data Abstractor

4 months ago

Jackson, United States West Tennessee Healthcare Full time

Job Description Summary

:JOB SUMMARY/SCOPE OF RESPONSIBILITY:
Performs clinical auditing and data abstraction of patient records in support of the organizations clinical quality improvement and patient safety initiatives associated with participation in various quality data reporting systems. Review results of audits and clinical quality improvement trends and opportunities with appropriate staff and service line leaders. Assists with identifying and implement processes to improve clinical care based on quality benchmarks. Keep data entry current, complete, and accurate to meet data submission deadlines, which are established by internal expectations and external regulations. Incumbent is responsible for the validity, reliability, and rapid access of abstracted clinical data. Assists with other data entry as needed, and maintain information system security and patient confidentiality. Employee will perform related responsibilities as required and directed. The Clinical Data Abstractor will be responsible for assigned shifts. Incumbent is subject to overtime and call back as required by the hospital. The Clinical Data Abstractor works closely with the Clinical Quality Improvement Director to meet the overall objectives and needs of the organization in regards to clinical quality improvement. Employee is subject to call back and overtime as required by the hospital.

ESSENTIAL JOB FUNCTIONS:

Performs data collection and reporting in compliance with specifications outlined by the assigned quality registry.

Collects related clinical data as defined by the measure/registry through efficient utilization of the hospital’s medical record systems.

Identifies opportunities for streamlining documentation and process improvement opportunities in the data collection process.

Responsible for the accurate, complete and timely entry of data into the program’s database. Collaborates with hospital staff and medical staff members to better understand data specifications and abstraction methodology as it pertains to clinical guidelines and best practice related to improvement in clinical quality.

Serves as an educational resource on clinical quality improvement opportunities related to the specific measure/registry for internal and external audiences as needed.

Communicate clearly any data documentation needs to support accurate and highly reliable data collection and reporting.

Provides timely and effective communication in regards to opportunities identified.

Keeps data current, complete, and accurate in order to reach data submission deadlines. 

Informs the Clinical Quality Improvement Director of quality activities and any opportunities for improvement.

Prepares special reports. Designs, completes and presents studies as requested.

Reviews individual charts as requested by the Clinical Quality Improvement Director and/or Chief Medical Officer/Chief Physician Executive, or designee.

Attends staff meetings as assigned. Attends monthly department meetings.

Completes continuing education for improvement of job performance.

Participates in organization/department activities and acts as a leader of teams when requested. Contributes to a positive work climate and overall team effort of the department and hospital, performs any related responsibility as required or directed and greets guest in accordance to our standards of performance.

Performs related responsibilities as required or directed.

JOB SPECIFICATIONS:

EDUCATION:

Skill and proficiency in the field of health care as acquired through completion of the requirement for Associate Degree in Nursing or Allied Health, Bachelor's Degree preferred. Minimum of 3 years of experience in area of clinical expertise. Knowledge and skills necessary to provide appropriate care and interventions to serve neonate, pediatric, adult, and geriatric patients.

LICENSURE, REGISTRATION, CERTIFICATION:

Current licensure as Registered Nurse or Allied Health Professional. AHA Basic Cardiac Life Support preferred.

EXPERIENCE:

Knowledge of accepted nursing procedures as acquired through 3 years of clinical experience preferred. Knowledge of the assessment of data, planning and coordination of care that will affect the management of patient care as acquired through on the job training. Knowledge of hospital policy and operations, medical and nursing staff procedures, and hospital resources as acquired through on the job training.

KNOWLEDGE, SKILLS AND ABILITIES:

Knowledge and understanding of computer programs, such as MIDAS, Outlook, Word, Excel, and Access. Experience in data entry is required and knowledge of quality / performance improvement and Six Sigma / Lean is desirable. Utilizes leadership / management skills. 

INTERPERSONAL REQUIREMENTS:

Ability to communicate effectively with all levels of hospital personnel, patients, families, and Medical Staff to direct activities, exchange information, provides technical / professional advice, and secure cooperation in providing patient care on a continuous basis. Must possess and demonstrate the necessary discretion in dealing with confidential information. Contributes to a positive work environment and the overall team effort of the department.

DIRECTION/SUPERVISION REQUIREMENTS:

Ability to lead team in a collaborative effort.

PHYSICAL DEMANDS:

Prolonged periods of sitting, standing, or walking on a continuous basis. Ability to perform infrequent moderate to heavy lifting and transporting of patients and equipment.

ENVIRONMENTAL CONDITIONS:

Possible exposure to contagious disease. Standard office conditions.

OTHER JOB REQUIREMENTS:

Dress - Nursing uniform or business attire that is professional, clean and reflecting the image of a business atmosphere. No denim uniforms / clothing. Lab coat recommended with business attire. Understands and adheres to West Tennessee Healthcare’s compliance standards as they appear in the Compliance Policy, Code of Conduct, and Conflict of Interest Policy. Assumes responsibility for insuring continued professional growth. The employee is expected to adhere to all WTH policies and procedures.

PROTECTED HEALTHCARE INFORMATION:

Minimum Necessary Requirement: This position has access to protected health information as defined in the category in WTH Management Guidebook Policy 7625. Employee will maintain confidentiality of protected health information and only access the minimum amount of protected health information necessary to perform job responsibilities.

DISCLAIMER:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this position. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required. All employees are required to perform duties outside of their normal responsibilities as required or directed.

NONDISCRIMINATION NOTICE STATEMENT

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.