Clinical Data Abstractor

Credence Global Solutions; Mumbai; Sur place; INR 450 000 - 650 000; Plein temps

Avantages offerts par ce poste

HIPAA training

Professional development

Competitive compensation

Résumé du poste

Credence Global Solutions in Mumbai, India is seeking a detail-oriented Clinical Data Abstractor to perform high-quality medical record abstraction. You will review and interpret clinical data from EHRs, paper charts and reports, capturing demographics, diagnoses, procedures and labs with accuracy.

Applicants should have 1+ year in data abstraction, strong medical terminology knowledge and experience with coding systems (ICD-10, SNOMED CT).

Qualifications

• Bachelor-level medical degree or equivalent (BHMS/BUMS/BDS/BPT).
• Minimum 1 year in clinical data abstraction or related field.
• Strong knowledge of medical terminology, coding and data encoding.
• Experience with EMR systems and data management practices.

Responsabilités

• Review, interpret and abstract clinical data from EHRs, paper charts and reports.
• Capture demographics, diagnoses, procedures, meds and lab results accurately.
• Apply inclusion/exclusion criteria and standard abstraction guidelines.
• Ensure data quality, validation and timely submissions.

Connaissances

Data abstraction

Medical coding

Attention to detail

Analytical thinking

EMR interpretation

Excel / Office

Formation

BHMS

BUMS

BDS

BPT

Outils

REDCap

EDC systems

Description du poste

Operations RCM

Profile Overview

We are seeking a detail-oriented and analytical Clinical Data Abstractor to perform high-quality medical record abstraction. The role combines proficient-level experience in data management and software with strong knowledge of medical terminology, medical coding, information encoding and analytical capability. The incumbent will review, interpret and manage complex clinical patient data for research, quality improvement, registry, regulatory reporting and healthcare analytics initiatives.

Job Roles & Responsibilities

• Review, interpret and abstract clinical patient data from electronic health record (EHR) systems, paper charts, medical charts, laboratory reports, physician notes and other source documents, in accordance with defined project or research protocols, clinical, data and technical specifications, and dictionaries.
• Accurately capture patient demographics, diagnoses, procedures, medications, laboratory results, outcomes and other required clinical variables.
• Apply standardized data abstraction guidelines and project-specific inclusion/exclusion criteria.

Coding and Classification:

• Apply knowledge of medical coding systems (e.g., ICD-10, ICD-10-CM, SNOMED CT, MedDRA, CPT, HCPCS) and standard-of-care guidelines to interpret, classify and categorize clinical data points from unstructured text into standardized, machine-readable data within one common database schema.
• Perform data mapping, standardization and harmonization as required by the project.

Electronic Data Capture and Data Management:

• Use specialized data management software (e.g., REDCap, registries, custom-built EDC systems and other clinical databases) to enter, track and maintain the integrity of clinical data in query able databases.
• Apply and support program-specific clinical data management best practices (CGDMP) and good clinical practice (GCP) so that data is accurate, legible, contemporaneous, original, attributable, complete and consistent across end-to-end ETL workflows.

Quality Assurance and Control:

• Perform data validation and quality checks to identify missing, inconsistent or inaccurate information.
• Apply industry-standard best practices for the use of real-world data in research, quality monitoring and regulatory reporting, using technical and analytical software.
• Participate in training, audits and periodic quality-assurance activities.

Protocol Adherence and Compliance:

• Maintain strict adherence to all project and research protocols, institutional review board (IRB) requirements, HIPAA and applicable data privacy regulations, data management best practices (e.g., DAMA, SCDM, ACRP and SOCRA) and organizational policies on patient privacy and data security.

Collaboration and Escalation:

• Collaborate with clinical, research, data management and quality teams to resolve data discrepancies and clarify documentation.
• Identify and upscale ambiguous or incomplete clinical information appropriately.

Daily Operations and Reporting:

• Provide timely and accurate daily, weekly or monthly abstraction submissions and productivity reporting.
• Meet established productivity, accuracy and turnaround-time requirements.
• Maintain documentation of abstraction decisions and follow standardized workflows.
• Actively participate in team meetings and workshops.
• Perform other duties and responsibilities as assigned.

Candidate Requirements

• Education: BHMS, BUMS, BDS, BPT or an equivalent physician degree.
• Experience: Minimum of 1 year of experience in clinical data abstraction and medical records review, or in a closely related role such as clinical research or healthcare data management. Experience in cancer, women's health or rare diseases is preferred.
• Clinical Knowledge: Strong knowledge of medical terminology, anatomy, physiology, common clinical conditions and disease processes (especially cancer), standard clinical workflows and genetic testing.
• Data Abstraction Expertise: Proven ability to accurately read, interpret and abstract complex clinical information from electronic and paper medical record sources, and to navigate EMRs and clinical documentation.
• Data Management Expertise: Direct experience performing clinical data encoding using standard ontologies, including but not limited to ICD-10-CM and SNOMED CT, along with data mapping, standardization and harmonization.
• Quality and Compliance: Demonstrated commitment to data integrity, quality control processes, and adherence to HIPAA and other data privacy regulations.
• Technical Proficiency: Proficiency with Microsoft Office (particularly Excel) or Google Suite, including creating pivot tables, generating reports and performing data analysis; working knowledge of clinical data systems and databases such as fillable forms, EDCs and data registries.
• Communication: Excellent written and verbal communication skills, with the ability to collaborate effectively with clinical and non-clinical teams.
• Autonomy: Proven ability to work independently, manage time, prioritize and organize tasks, and meet strict productivity and quality deadlines.
• Certifications: Maintenance of all relevant clinical or technical licensures and certifications, where applicable.

General Expertise:

• High level of initiative and self-motivation.
• Able to work as part of a team on high-visibility projects with high rates of communication.
• In-depth attention to detail and a fast learner.
• Responsive to shifting priorities and changes.

KEY COMPETENCIES

• Clinical knowledge and medical terminology
• Data quality management
• Medical coding and data encoding
• Data abstraction and validation
• Attention to detail
• Analytical and critical-thinking skills
• Time management and prioritization
• Confidentiality and compliance
• Communication and teamwork
• Initiative, self-motivation and adaptability to shifting priorities

PERFORMANCE EXPECTATIONS

• Maintain high levels of abstraction accuracy and consistency.
• Complete assigned records within established turnaround times and meet productivity and quality deadlines.
• Identify and upscale ambiguous or incomplete clinical information appropriately.
• Consistently follow project-specific abstraction guidelines, protocols and quality standards.
• Safeguard patient confidentiality and always comply with HIPAA and data security requirements.