Clinical Data Abstractor II

HonorHealth; Arizona; Remote; USD 60,000 - 85,000; Full time

Job summary

HonorHealth in Arizona is seeking a Clinical Data Abstractor II to abstract and audit complex clinical records for registries, ensuring compliance with care standards and accreditation requirements. This remote position requires Arizona residency.

The role applies nursing training to data extraction, variance reporting, and collaboration with clinical leadership. RN license is required; BSN preferred; experience with CMS Core Measures or NSQIP is a plus.

Qualifications

• Abstracts/audits moderate to highly complex clinical data.
• Ensures compliance with standards, policies, and regulations.
• Identifies variances and reports findings to leadership.

Responsibilities

• Abstract/audit complex clinical data and enter findings into registry software.
• Maintain competency in measure specifications and protocols.
• Identify concerns, summarize findings, and communicate with leadership.
• Collaborate with stakeholders and participate in meetings.
• Follow up with patients/providers postoperatively for registry data.
• Support quality assurance audits and inter-rater reliability.
• Perform other duties as assigned.

Skills

Clinical data abstraction

Data auditing

Regulatory compliance

Healthcare documentation

Communication with leadership

Education

Associates Nursing

Bachelors Nursing

Tools

Registry software

Job description

Primary City/State: Virtual Arizona

Category: Health Information

Shift: Day

Department: Quality Improvement Division

Monday - Friday 8:00am - 4:30pm - remote position.

Virtual Training.

Must reside in the state of Arizona.

Great care starts with great people. (Like you.)

At HonorHealth, you'll find something special. From humble beginnings in 1927 to one of Arizona's largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most - caring for the health and well-being of people and communities across the greater Phoenix area.

Responsibilities:

JOB SUMMARY

The Clinical Data Abstractor II abstracts and/or audits clinical records, data or other information. The Clinical Data Abstractor II applies clinical training, knowledge and experience in the review of moderate to highly complex clinical information from individual patient records and other sources to abstract data elements for clinical registries and to ensure compliance with standards of care, policies and procedures, regulations or accreditation requirements. In addition, the Clinical Data Abstractor II will identify and report variances from established guidelines, significant data trends, outlier values or unusual data for additional review by physicians, operational and/or quality leadership.

ESSENTIAL FUNCTIONS

• Utilizes clinical training, knowledge, and experience to abstract/audit moderate to highly complex clinical data; Maintains accuracy in abstraction/audit by following published guidelines, abstraction specifications and/or other established standards; Enters data elements or audit findings into registry software and/or other data collection tools or software within established deadlines; Maintains established productivity standards
• Maintains competency in measure and/or registry specifications, definitions, and protocols for work assigned by participating in teleconferences, webinars, conferences, and reviewing updated documentation.
• Identifies potential areas of concern/interest; summarizes findings and draws conclusions; maintains ongoing variance reports and communicates findings to clinical data abstractor lead and/or director in a timely manner.
• Established effective working relationships with key stakeholders, teams, and committees; attends meetings as appropriate to disseminate findings, provide education, and answer questions.
• Contacts patients, families, and/or provider outpatient clinics via telephone and/or written communications postoperatively for the purpose of identifying clinical outcomes and completing required registry follow-up documentation.
• Facilitates and participates in quality assurance audits of abstracted/audited data to ensure a high level of inter-rater reliability among the clinical data abstractor team and achievement of acceptable validation results from external audits.
• Performs other duties as assigned.

EDUCATION

• Associates Nursing Required
• Bachelors Nursing Preferred

EXPERIENCE

• 3 years experience working in acute care hospital setting. Required
• 1 year auditing or abstraction experience. Preferred
• 2 years experience in abstracting CMS Core Measures or Clinical Outcomes Registries (NSQIP, STS, ACC, VON NICU, GWTG, etc.) Preferred
• Other Acute care experience in surgery, cardiac, emergency or critical care. Preferred

LICENSES AND CERTIFICATIONS

• Registered Nurse (RN) - License Valid State of Arizona or compact state Registered Nurse license. Required
• Candidates hired and assigned to the ACS NSQIP or MBSAQIP registry must complete surgical case reviewer training/certification within 90-days of hire (training provided/paid by organization) 90 Days Required

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