Clinical Abstractor

Albert Einstein Medical Center; Philadelphia (Philadelphia County); On-site; USD 52,000 - 67,000; Full time

Job summary

Albert Einstein Medical Center in Philadelphia is seeking a Clinical Data Abstractor to review medical records and abstract key data elements into quality measure registries. You will ensure accurate, timely documentation for internal quality review and external reporting, with access to the Registry and unrestricted medical records.

Responsibilities include data abstraction for national quality measures, reporting, and ongoing training to maintain skills.

Qualifications

• Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease process required.
• Associate’s Degree or BS in Health Information Management, Nursing or related field; Prior work in medical record abstraction preferred; knowledge of Medisolv and Get with Guidelines abstraction systems preferred.

Responsibilities

• Interact with co-workers and staff to abstract records per quality measures.
• Record findings in MBASQIP, NSQIP, Get with Guidelines and Medisolv abstract forms and/or direct data entry into the Registry.
• Create reports for Quality Department to evaluate clinical practice trends.
• Attend inservice trainings to maintain abstraction skills.

Skills

Medical terminology

Education

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

Tools

Medisolv

Get with Guidelines

MBASQIP

NSQIP

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

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

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

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

Preferred Qualifications

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.

Additional Qualifications

Additional Qualifications 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

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

Work Shift Rotating (United States of America)

Worker Sub Type

Worker Sub Type Regular Employee

Entity

Entity Albert Einstein Medical Center

Primary Location Address

Primary Location Address 5501 Old York Road, Philadelphia, Pennsylvania, United States of America

Company Overview

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 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

EEO Statement

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Benefits Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance. For more benefits information, please click here In keeping with Jefferson's Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees.

Join Us

If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson. Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education. With a long standing history, Jefferson has been advancing the medical field from the heart of Center City Philadelphia for nearly 200 years. Our Mission, We Improve Lives, expands to every corner of the organization. From our weekly farmer’s market, to our new Jefferson Accelerator Zone for innovation, our employees’ passion for the community is evident by the daily gestures towards our patients, students and each other.