Clinical Data Abstractor II

About the role

This is a remote position based in Arizona, with virtual training provided. The Clinical Data Abstractor II abstracts and/or audits clinical records, data, or other information, applying clinical training and experience to review moderate to highly complex clinical data from patient records and other sources. Responsibilities include abstracting data elements for clinical registries, ensuring compliance with care standards, policies, regulations, and accreditation requirements, and identifying variances or trends for further review.

Responsibilities

• Utilizes clinical training, knowledge, and experience to abstract/audit moderate to highly complex clinical data.
• Maintains accuracy in abstraction/audit by following published guidelines, specifications, and established standards.
• Enters data elements or audit findings into registry software or other data collection tools within established deadlines.
• Maintains established productivity standards.
• Maintains competency in measure and/or registry specifications, definitions, and protocols through participation in teleconferences, webinars, conferences, and reviewing updated documentation.
• Identifies potential areas of concern, summarizes findings, and draws conclusions; maintains ongoing variance reports and communicates findings to leadership.
• Establishes effective working relationships with stakeholders, teams, and committees; attends meetings to disseminate findings, provide education, and answer questions.
• Contacts patients, families, and provider outpatient clinics via telephone or written communications postoperatively to identify clinical outcomes and complete registry follow-up documentation.
• Facilitates and participates in quality assurance audits to ensure high inter-rater reliability and acceptable validation results from external audits.
• Performs other duties as assigned.

Requirements

• Associate’s degree in Nursing (required); Bachelor’s degree in Nursing (preferred).
• 3 years of experience working in an acute care hospital setting (required).
• 1 year of auditing or abstraction experience (required).
• 2 years of experience in abstracting CMS Core Measures or Clinical Outcomes Registries (e.g., NSQIP, STS, ACC, VON NICU, GWTG) (preferred).
• Acute care experience in surgery, cardiac, emergency, or critical care (preferred).
• Valid State of Arizona or compact state Registered Nurse (RN) license (required).
• Candidates assigned to the ACS NSQIP or MBSAQIP registry must complete surgical case reviewer training/certification within 90 days of hire (training provided/paid by organization).

Schedule

Monday - Friday, 8:00 AM - 4:30 PM (remote position). Must reside in the state of Arizona.