Clinical Abstractor

Jefferson Health; Philadelphia (Philadelphia County); On-site; USD 55,000 - 75,000; Full time

Job summary

Jefferson Health seeks a Clinical Data Abstractor to review medical records and abstract key data elements into quality measure and clinical registry databases. The role ensures data accuracy, timeliness, and adherence to documentation standards for quality healthcare data.

The position requires working within an integrated organizational framework with access to medical records to complete timely data entry and reporting for internal quality reviews and external agencies.

Qualifications

• Extensive knowledge of medical terminology, anatomy, physiology and clinical disease processes.
• Preferred: Associate’s Degree or BS in Health Information Management, Nursing or related field.
• Experience with medical record abstraction preferred.

Responsibilities

• Interacts with staff and patients to ensure accurate data abstraction.
• Abstract, classify and record clinical information for quality measures and registries.
• Ensure data entry into MBASQIP, NSQIP, Get with Guidelines and related systems.
• Produce reports for Quality Department to analyze practice trends.
• Maintain daily productivity logs and meet accuracy thresholds.

Skills

Medical terminology

Anatomy & physiology

Clinical disease knowledge

Education

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

Tools

Medisolv

Get with Guidelines (GWTG)

Microsoft Office

Job description

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.

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.

Summary

Job Description

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

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

About Jefferson

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.

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

• 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.

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