RN Clinical Data Abstractor - Quality Outcomes

Job Summary

Responsible for abstracting and/or auditing a large volume of clinical case records, data, or other information within established deadlines in support of PeaceHealth's quality assessment and performance improvement program and compliance with regulatory and accreditation requirements.

Applies clinical training, knowledge and clinical experience in the review of moderate to highly complex clinical information from individual patient records and other sources to abstract data elements for clinical registries and to ensure compliance with standards of care, policies and procedures, regulations or accreditation requirements.

Produces reports addressing variances from established standards, and identifies significant data trends, outlier values or unusual data for additional review by physicians, clinical value improvement staff and/or leadership. Responsible for the integrity of the reported data.

Essential Functions

• Manages, schedules and receives patient records for abstracting from multiple PeaceHealth hospitals;
• Abstracts moderate to highly complex clinical data using established definitions and abstraction guidelines;
• Maintains an abstracting volume to meet internal and external reporting deadlines.
• Enters abstracted data into the appropriate registry or third-party vendor software within the established deadlines for data submission.
• Conducts or coordinates audits of patient records or other information to support the quality assurance and performance improvement program in each PeaceHealth community and evaluates compliance with established standards and/or regulatory and accreditation requirements.
• Identifies potential areas of concern/interest; interprets actual trends and develops reports that display variances from established standards of care or regulatory standards; summarizes findings and draws conclusions; maintains ongoing variance reports and communicates findings to provider, clinical value improvement caregivers and/or leadership in a timely manner; works with providers to interpret data trends and/or variances.
• Maintains accuracy in abstraction by following published guidelines and abstraction specifications; maintains accuracy and integrity of audit information by following standards and guidelines; facilitates and participates in quality assurance audits of abstracted/audited data to ensure a high level of inter-rater reliability among the clinical data abstractor team and achievement of acceptable validation results from external audits.
• Creates case finding or internal audit reports in an acceptable format for additional review by providers, clinical value improvement caregivers and/or leadership.
• Participates in teleconferences, webinars, and/or onsite educational opportunities. Shares knowledge with clinical value improvement caregivers and teams.
• Participates in team or committee meetings to present and discuss data and identify trends as appropriate.
• Performs other duties as assigned.

Qualifications

• Education: Associate Degree Required: Nursing Bachelor's Degree Preferred: Nursing
• Experience: Minimum of 3 years Required: clinical experience in an acute care hospital or care management and/or hospital insurance case management experience Preferred: Experience in surgery, inpatient care and emergency services, or an Advanced Nurse Practitioner degree Preferred: Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity
• Credentials: Required: Registered Nurse in state of practice Preferred: Certified Professional in Healthcare Quality
• Skills: Advanced knowledge of medical terminology, anatomy and physiology and understanding of disease processes, pharmaceuticals, and diagnostic studies (Required) Strong organization, analysis, software aptitude, and communication skills (both written & verbal) (Required) Proficient skills in database management, spreadsheets, word processing, graphs and presentations (Required) Proficient with MS Office applications (Required) Demonstrated experience working successfully with physicians and clinicians (Required) Current knowledge of regulatory and accreditation requirements related to data abstraction and reporting, quality assurance, performance improvement and required measurement systems (Required) Knowledge of current clinical practice standards as demonstrated by recent clinical experience or adequate continuing education (Required)

Skills

• Advanced knowledge of medical terminology, anatomy and physiology and understanding of disease processes, pharmaceuticals, and diagnostic studies
• Strong organization, analysis, software aptitude, and communication skills (both written & verbal)
• Proficient skills in database management, spreadsheets, word processing, graphs and presentations
• Proficient with MS Office applications
• Demonstrated experience working successfully with physicians and clinicians
• Current knowledge of regulatory and accreditation requirements related to data abstraction and reporting, quality assurance, performance improvement and required measurement systems
• Knowledge of current clinical practice standards as demonstrated by recent clinical experience or adequate continuing education

Environmental Conditions

• Lifting: Consistently operates computer and other office equipment.
• Sedentary work.
• Predominantly operates in an office environment.
• Some time spent on site in medical/hospital setting.
• Mental/Visual Ability: To communicate and exchange accurate information.
• The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.

Benefits

• Full medical/dental/vision coverage
• 403b retirement plan employer base and matching contributions
• Paid time off
• Employer-paid life and disability insurance with additional buyup coverage options
• Tuition and continuing education reimbursement
• Wellness benefits
• Expanded EAP and mental health program