RN Clinical Data Abstractor II

Virtual position based in Arizona. Monday - Friday, 8:00am - 4:30pm. Remote work with virtual training. Must reside in the state of Arizona.

About the role

The Clinical Data Abstractor II abstracts and/or audits clinical records, data, or other information. This role applies clinical training, knowledge, and experience to review moderate to highly complex clinical information from individual patient records and other sources. The goal is to abstract data elements for clinical registries and ensure compliance with standards of care, policies, procedures, regulations, or accreditation requirements. The role also involves identifying and reporting variances, significant data trends, outlier values, or unusual data for additional review by physicians, operational, and/or quality leadership.

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, abstraction specifications, and/or other established standards.
• Enters data elements or audit findings into registry software and/or other data collection tools within established deadlines.
• Maintains established productivity standards.
• Maintains competency in measure and/or registry specifications, definitions, and protocols by participating in teleconferences, webinars, conferences, and reviewing updated documentation.
• Identifies potential areas of concern/interest; summarizes findings and draws conclusions; maintains ongoing variance reports and communicates findings to clinical data abstractor lead and/or director in a timely manner.
• Establishes effective working relationships with key stakeholders, teams, and committees; attends meetings as appropriate to disseminate findings, provide education, and answer questions.
• Contacts patients, families, and/or provider outpatient clinics via telephone and/or written communications postoperatively to identify clinical outcomes and complete required registry follow-up documentation.
• Facilitates and participates in quality assurance audits of abstracted/audited data to ensure high inter-rater reliability among the clinical data abstractor team and achievement of 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 (preferred).
• 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).

Qualifications

• Registered Nurse (RN) - License valid in the State of Arizona or a compact state (required).
• Candidates hired and 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, 8:00am - 4:30pm.