Clinical Abstraction Partner

Job Description:

Professional clinical data abstractors/registrars support the on-going work of performance improvement through the enterprise by performing high-quality data abstraction, compilation, validation, for clinical registries using clinical expertise to support abstraction activities and support/educate team members related to registry domain topics.  The abstractors/registrar partner with registry owners in the identification of opportunities and performance improvement activities. The registries may include federal/accreditation program, third-party gold standard registries, and internal regulatory required abstraction/registries. These registries are critical in support of CMS/TJC regulatory requirements, Clinical Excellence, Clinical Services and Programs for quality improvement and identification of improved outcomes.   

** Different professional organizations, registries or Centers of Excellence designation utilize different names for staff who function as an abstraction, specialist, or registrar.  This job description is an Intermountain job description to meet these requirements.  

Clinical experience in neonatal care, particularly with newborns, is preferred for this role.

Essential Functions 

• Execute professionally and expertly the technical work of abstraction specific to the specifications of the registry   The technical work includes abstraction and input of clinical element from the Electronic Health Record (EHR), validation, submission, compliance to Intermountain and registry privacy standards, maintain registry specific competency, education &/or certification requirements, and support performance improvement activities. Supports non-clinical abstractors with training / education related to clinical expertise in abstraction  

• When allowed by a registry, they use clinical professional skills to understand healthcare workflows and interpret documentation as it relates to abstraction. Assists in identification of clinical, financial, and risk issues and escalates them to the supervisor as appropriate.  

• Establishes and maintains relations with key registry stakeholders as a trusted partner in the performance improvement related to registry work. Supports registry owner meetings and processes with expertise to clarify, inform, identify opportunities, outcomes review, and support performance improvement work.  Performs standard work duties as assigned in the structured work.   

 

Skills 

• Hospital Care Experience 

• Clinical Care  

• Communication 

• Teamwork 

• Regulatory Compliance 

• Quality Improvement Focus 

• Data Abstraction 

• Documentation 

• Health Information  

• Medical Record Management 

• Clinical Databases 

 

Qualifications 

Minimum Requirements  

• Current LPN, RN, Pharmacist, Respiratory Care, Radiology Technology or Healthcare Professional license or practice as a Cardiac Cath Lab technician.  

• Three years of clinical work experience in clinical areas of registry.  

• Excellent written and verbal communication skills.  

• Experience utilizing knowledge of medical terminology and anatomy.  

• General computer skills, including word