Data Abstractor Lead

Facility: VIRTUAL-GA

Job Summary: Disease specific clinical data abstraction from the patient record and entering into the appropriate registry/database. Must become knowledgeable in disease specific specifications, chart/data abstraction process and data entry process. Must be very accurate and attentive to detail because the data is used for government public reporting, pay for performance and physician credentialing. The data abstraction, validation and analysis must be completed timely and have quality control checks. This position reports to the Managers and Director Public Reporting.

Core Responsibilities and Essential Functions:

• Abstract clinical information from the clinical record.
• Services as disease specific specification expert.
• Keeps up with new specifications and changes every 6 months.
• Reviews charts and abstracts required data element into data base.
• Researches specifications and or QNET or other appropriate support groups when uncertain if documentation is acceptable.
• Keeps accurate list of cases abstracted and completed.
• Works closely with medical records to correct and/or add any missing documents to the chart.
• Works to get DC status, admission source, and HIC numbers corrected on the final chart.
• Meet all data submission deadlines Accurate entry of clinical data into the database.
• Runs error reports after data entry and corrects all errors.
• Reviews missed opportunity cases with Best Practice nurse, makes corrections if needed.
• Reviews validation reports on a quarterly basis and keeps accuracy at or greater.
• Any questions or concerns regarding diagnosis codes discuss and review with coding manager.
• If coding changes needed work with vendor to make changes. Assist with education of disease specific specifications.
• Works with Best Practice nurses and physicians, committees, work groups to understand the specifications and required documentation.
• Explains why cases fail the measurement set and/or meet the set. Collaborate with designated Performance Improvement Committee, PIC, or defined workgroups.
• Work with PICs and Best practice nurses to improve processes by identifying barriers to success.
• Work with the IT team and Zynx to create order sets that incorporate best practice and required documentation.
• Prepare and present data relating to the Measurement set to PICs. Monitor and report any practice trends identified during the data collection process.
• Assist with running physician level reports used for reappointment.
• Watch for positive and or negative trends with data and bring to attention of teams.
• Recognize those doing well. Other duties as requested by the PR Manager/Director.
• Communicate with the vendor if there any issues with the WEB tools and bring to managers attention.

Required Minimum Education:

• Associate's Degree Required and Bachelor's Degree Preferred and Graduate of accredited nursing program with RN Required or graduate with associates degree from accredited clinical field relevant to the clinical database. Required and accredited courses of study include: Pharmacy, Respiratory therapy, Psychology: Behavioral Health. Preferred

Required Minimum License(s) and Certification(s):

• Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred

Required Minimum Experience:

• Minimum 6 years experience in a relevant clinical or acute care nursing unit, e.g., ICU, CCU, medical surgery area, Behavioral Health, or in area of healthcare work relevant to positions requisite knowledge. Required and Clinical experience related to biostatistics, epidemiology, clinical trials/public health research, or applied health informatics will also be taken into consideration if relevant to specific role duties. Required and Minimum 1 year with clinical data abstraction. Required and experience giving presentations to panels and large groups. Required

Required Minimum Skills:

Intermediate to advanced computer skills to include, but not limited to: entire MS Office Suite: i.e., Word, Excel, Power Point, Visio. Proficient at assessing clinical workflows within an EHR (electronic health record) related to quality measurement concepts or clinical performance metrics. This individual should have expertise in working with abstracted health care data (from claims, billing, electronic health record, etc.) and experience working in clinical settings. Strong organizational skills and high level of attention to detail; flexibility to lead and manage multiple priorities, sometimes simultaneously, under deadlines. Understanding of the NQF endorsement process and/or CMS Quality Measures Management System concepts. Experience and knowledge of Publicly Reported CMS, state, and other quality reporting programs or relevant clinical quality registry databases. Working knowledge of standards used in quality measure logic. Must possess excellent oral and written communication skills; ability to write clear and concise technical memos, documents and reports; Ability to develop collaborative relationships and effectively execute the clinical programs goals and objectives each role supports. Must possess understanding of team dynamics, strong critical thinking, attention to detail and time management. Must have the ability to work independently and maintain focus on goal attainment.