Description
Performs primary data abstraction duties for Core Measures and ensures high levels of abstraction accuracy for assigned accounts via validation activities. Demonstrates strong communication, documentation, organizing, and planning skills to ensure strong leadership of multiple accounts concurrently.
Responsibilities
• Collects and abstracts data from patient medical records, especially those related to disease-specific care. This includes information on diagnoses, treatments, procedures, and outcomes.
• Ensures the accuracy and completeness of the abstracted data. This involves cross-referencing information from multiple sources within a patient’s medical record.
• Adheres to specific clinical data abstraction guidelines and standards, such as those set by the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC).
• Enters the abstracted data into a database or registry, often using specialized software. This includes maintaining and updating the data as necessary.
• Participates in quality assurance processes to ensure data integrity. This involves regular audits of the data or the abstraction process.
• Remains informed about developments in patient care and data management to ensure ongoing competency in the role.
Qualifications
• Experience abstracting Core Measures within the last 2 years is required.
• Familiar with medical records, billing/documentation practices, and standard healthcare quality concepts.
• Proficient in Microsoft Office.
• Ability to work independently.
• Relies on experience and judgment to plan/accomplish goals.
• Maintains a strict level of confidentiality in all aspects of work.
• Demonstrates a high standard of accuracy and attention to detail.
• Excellent interpersonal communication skills.
• BSN, LPN, or RN preferred.
