About this role
Clinical Abstractor - Remote Possible - FT
Job Description:
Clinical Abstractor
A Clinical Data Abstractor reviews, analyzes, and summarizes relevant patient information from medical records. The data is then compiled into a structured format for various purposes, including quality improvement initiatives, regulatory reporting, clinical research, and billing.
- 0.5 FTE assigned to Trauma
- Remaining time assigned to Core/Sepsis abstraction
Principal Duties and Responsibilities
- Extracts and abstracts specific clinical data points from medical records, electronic health records (EHRs), and other medical documentation according to established protocols and definitions.
- Reviews abstracted data to ensure its accuracy, consistency, and completeness, often performing quality audits to maintain data integrity.
- Prepares and submits accurate and timely data to various registries or quality reporting systems, such as those related to specific procedures, disease processes, or national measures (e.g., Core Measures).
- Identifies and communicates opportunities and trends based on data findings to improve clinical processes and patient safety.
- Communicates and collaborates with clinical staff, management, and other healthcare professionals to clarify documentation and resolve data discrepancies.
- Aids in the collection and organization of data for research, clinical trials, epidemiological studies, or other data-driven initiatives.
- Arrays data for presentation in a format that is clear and understandable to audience.
- Maintains an interrater reliability at or above 95%.
Skills and Abilities
- A strong understanding of medical terminology, anatomy, disease processes, and medical coding systems (e.g., ICD-10) is essential.
- Familiarity with Epic EHR, data abstraction software, and data management tools like Microsoft Excel is preferred.
- Excellent attention to detail and a high standard of accuracy are crucial for ensuring the reliability of data.
- Strong analytical and problem-solving skills are needed to review complex records and identify relevant data points.
- The ability to work independently, manage multiple tasks, and maintain organized records is necessary.
Required Education
- RN preferred.
- Association of the Advancement of Automotive Medicine’s Abbreviated Injury Scale (AIS) course required within 6 months of hire.
- Trauma registry course required within 6 months of hire.
- ICD-10 course within 6 months of hire and/or an ICD-10 refresher course every 5 years required.
- Accrue 24 hours of trauma-related CE during the trauma verification cycle (3 years) required.
- Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) within 2 years.
Compensation Grade: G
Compensation Grade Profile: G - Hourly
Bay Area Hospital is an Equal Opportunity Employer.
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