Clinical Data Abstractor, Greenville, PRN, Variable

Inspire health. Serve with compassion. Be the difference.

Job Summary

The Clinical Data Abstractor is responsible for collection, validation and clinical quality review of patient-level data for national clinical quality initiatives (i.e., CMS core measures) or other clinical data registries (i.e. heart failure, cancer, stroke, etc.) necessary to support mandatory reporting, specialty centers of excellence, accreditation or certification requirement. The scope of the clinical data abstractor work involves: managing the overall medical record retrieval process for abstracting the required data; collecting numerous complex data elements using established definitions; ensuring the integrity of the electronic data transmitted to an established national database/registry; preparing and interpreting clinical data reports and working with clinical team members on quality improvement projects. The position translates clinical documentation into information that can be used for actionable improvement; recognize and identify variances between and within systems, evaluate potential causes of variation and work collaboratively to support action plans for clinical care improvement. The position supports the organization/market/campus or care setting's clinical and administrative leadership team, quality leadership, subject matter experts (SMEs), stakeholder groups and ad hoc teams related to data abstraction and performance improvement. Provides guidance, consultation, and standard work for the design and maintenance of registry and clinical databases. All team members are always expected to be an example of Prisma Health values.

Accountabilities

• Abstract clinical data elements from the electronic medical record per guidelines/ definitions of the patient-selection criteria and sponsoring/regulatory entity (e.g. CMS Core Measures) or clinical-related databases or registries; develop efficient data collection and data management processes; ensure data integrity through validation and clarification of case questions; maintain proficiency and productivity in terms of volume of patient records assessed and abstracted. - 70%

• Upload/submit data files to sponsoring organization and investigate/correct data submission errors; work with key stakeholders to resolve questions, issues or problems related to software, report capacity, benchmarking reports, etc. – 10%

• Foster collaboration between abstraction staff and clinical leaders to achieve the required results for quality patient care and accurate documentation for data abstraction and submission.  - 10%

• Meet with specific clinical stakeholders to report on quality outcomes, performance and compliance results.– 10%

• Perform a detailed medical record review when deviation or non-compliance with practices is determined; identify trends and patterns; provide feedback to key stakeholders. – 10%

Supervisory/Management Responsibilities

This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Associate Degree - Preferred education in one or more of the following areas: Healthcare related field,  Health Information Management

• 2 years - Knowledge of human anatomy, medical terminology, electronic medical record, data abstraction/data entry. Clinical data abstraction, data management or data entry experience preferred.

Required Certifications, Registrations, Licenses

• If working with Cancer registry, a CTR (Certified Tumor Registrar) Certification by the National Cancer Registrars Association (NCRA) is required within one year of employment.

Knowledge, Skills or Abilities

• Basic Computer Skills

• Knowledge of office equipment (fax/copier)

• Proficient computer skills (word processing)

• Proficient computer skills (spreadsheets)

• Proficient computer skills (database)

• Data Entry

• Mathematical Skills

• Electronic Health Record

• Proficiency in Microsoft Word, Excel and PowerPoint - Required

• Experience in quality improvement, clinical data review, and performance improvement methodologies; ability to effectively communicate opportunities for improvement.

• Detail oriented; ability to work independently and to adhere to standards/definitions of sponsoring agencies/ entit