Sr Clinical Data Abstractor

Abstract data from medical records/EMR or other tools using the appropriate guidelines to provide accurate and timely information for the department's customers,, TJC and CMS. Trains and educates internal and external customers on the core measure rules guidelines. Review outlier charts for accuracy and performs and record Inter-Rater-Reliability (IRR) checks. Network with departmental customers using various techniques to team building using various communication techniques.

What You Will Do

• Abstracts data records from multiple sources or other tools using the appropriate guidelines/rules to provide accurate and timely information for the department and its customers.
• Is knowledgeable about and performs daily operational processes for abstracting and utilizing tools and programs used in data collection.
• Performs data entry and validation as directed and needed.
• Attends departmental/external meetings and networks with customers and department and team members to share expertise and expand knowledge base.
• Assists with compiling, tracking, and performing data quality reviews as a continuous process; including computing overall and individual scores, tracking and trending results and errors, while also overseeing that corrections are made and accuracy is ensured.
• Responsible for staying current with changes in the guidelines/rules for data collection and abstraction; including notifying and training internal and external team members on the guideline changes and specifications.
• Assists with training and educating internal and external members, including new staff, on the core measures, core measure specifications, abstraction guidelines, and overall process of abstraction for each core measure topic; including how to navigate the vendor interface, how to navigate the EMR, and how to use other applications, tools and software.
• Responds to and provides information for requests for information in a timely and accurate manner. This includes requests from both internal and external colleagues.
• Reviews Opportunities for Improvement (OFI) for peers to ensure accuracy and confirm the OFI.
• Completes special projects and prepares tools for collection as requested, as needed.

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.