Clinical Abstractor

jeffersonhealth; Philadelphia (Philadelphia County); On-site; USD 62,000 - 86,000; Full time

Job summary

Jefferson Health in Philadelphia is seeking a Clinical Data Abstractor to review medical records and abstract key data elements into quality measure and clinical registry databases. Data accuracy and timeliness are essential to support internal quality review and external reporting.

This role is integrated into the organizational framework with access to medical records to fulfill duties, including timely data entry to the Registry and reporting to accrediting bodies.

Qualifications

• Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease process required.
• Preferred: Associate's Degree or BS in Health Information Management, Nursing or related field.
• Experience with medical record abstraction activities preferred; familiarity with Medisolv and GWTG systems is a plus.

Responsibilities

• Abstract, interpret and classify clinical information in the medical record for quality measures and registry data collection.
• Review and abstract records for specific patient populations for compliance with Joint Commission and quality criteria.
• Record findings in abstraction forms and enter data into registry databases; create reports for Quality Department.
• Participate in inservice trainings to maintain abstraction skills and meet productivity targets.

Skills

Medical terminology

Anatomy & physiology

Clinical data accuracy

Documentation practices

Education

Associate's Degree or BS in Health Information Management, Nursing or related field

Tools

Medisolv

Get with Guidelines (GWTG)

Microsoft Office

Job description

Number of Positions In Requisition

1

Job Details

The Clinical Data Abstractor reviews medical records and abstracts key data elements into the quality measure and clincial registry databases. Data accuracy and timeliness maintained to support ongoing needs of internal quality review and process improvement as well for reporting to outside agencies. Supports the importance of accurate, complete, timely and consistent documentation practices for the production of quality healthcare data.

This position is fully integrated into the organizational framework and has the authority and resources to fulfill all the duties outlined above, including timely data entry to the Registry with full and unrestricted access to medical records.

Job Description

Summary

The Clinical Data Abstractor reviews medical records and abstracts key data elements into the quality measure and clincial registry databases. Data accuracy and timeliness maintained to support ongoing needs of internal quality review and process improvement as well for reporting to outside agencies. Supports the importance of accurate, complete, timely and consistent documentation practices for the production of quality healthcare data.

This position is fully integrated into the organizational framework and has the authority and resources to fulfill all the duties outlined above, including timely data entry to the Registry with full and unrestricted access to medical records.

Job Duties Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson

• Abstract, interpret and classify clinical information in the medical record according to the Specifications Manual for National Hospital Inpatient and Outpatient Quality measures as it relates to quality abstraction data collection to benchmark against other hospitals and for submission to accrediting agencies
• Review and abstract records for certain patient populations for compliance with The Joint Commission ORYX and Quality Measures criteria.
• Clearly and accurately record all findings in MBASQIP, NSQIP, Get with Guidelines (GWTG) and Medisolv abstract forms and/or direct data enter findings into the Registry databases and tracking forms. Create reports for Quality Department to evaluate clinical practice trends.
• Participate in Quality Abstraction inservice meetings or training sessions to maintain and enhance abstraction skills, to stay abreast of changes in abstraction guidelines/regulations. Attend interdisciplinary meetings to review quality measure data outcomes and process. Enter daily productivity into the Clinical Data Abstraction Productivity log. Consistently meet or exceed departmental minimum accuracy and productivity rates.

Minimum Qualifications

Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease process required.

Preferred Qualifications

Associate's Degree or BS in Health Information Management, Nursing or related field

Previous work experience in medical record abstraction activities preferred.

Knowledge of Medisolv and Get with the guidelines abstraction systems preferred.

Familiarity with computers and Miscrosoft Office applications preferred.

Physical Demands

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Rotating (United States of America)

Worker Sub Type

Regular

Employee Entity

Albert Einstein Medical Center Primary Location Address 5501 Old York Road, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top