Data Abstractor - At Home

UPMC

1d•Remote

About The Position

The Data Abstractor reviews patient medical records to extract key data for quality reporting required by CMS, state and federal agencies, and Value-Based Care programs. Accurate and timely data submission is critical to avoid financial penalties. The Abstractor manages the data retrieval process by manually abstracting complex elements from electronic health records (EHR) and validating electronic data capture. This involves applying measure-specific definitions, inclusions, and exclusions from multiple specification manuals. They also ensure data integrity by validating CMS eCQMs, identifying and reporting electronic capture errors, and flagging documentation or workflow issues to improve clinical outcomes. The role supports clinical care improvement by translating documentation into actionable insights and identifying system variances. This full-time position will work daylight hours with flexibility to start between 6AM to 8AM Monday through Friday. The position will work remotely; however, it is a preference for individuals to be based in Pennsylvania in case of system outages to go into a local UPMC site.

Requirements

A high school graduate with a minimum of one to two years of clinical or quality measure abstracting experience OR CMS, AHA, and TJC abstracting experience between 2015 to present calendar year OR nurse OR completion of a certified nurse assistant certificate program.
A strong knowledge in anatomy, physiology, pharmacology, and medical terminology is required.
Good written and oral communication and organizational skills is required.
Must possess high degree of concentration to accurately apply measure specifications to abstract data from patient records.
Must be detail oriented to assure accuracy of abstracted data and be able to identify issues within the systems used for abstracting.
Must demonstrate ability to work under pressure in a positive team-oriented manner with diplomacy and tact.
Computer skills of Microsoft Office applications and Internet use are required.

Nice To Haves

Cerner or similar clinical e-record system.
Knowledge of CMS IQR, OQR, IPFQR quality measure reporting program abstraction; AHA/GWG Stroke abstraction, and CMS eCQM program preferred.
A graduate of an approved accredited Registered Health Information Technician Program (RHIT or eligible) is preferred but not required.

Responsibilities

Responsible for collection, review, and validation of patient level data, including but not limited to, national clinical quality initiatives such as the CMS programs for Inpatient (IP) Quality Reporting (IQR) that includes electronic Clinical Quality Measures (eCQMs), Outpatient (OP) Quality Reporting (OQR), Inpatient Psychiatric Facility Quality Reporting (IPFQR), all of which are required to financially maintain the CMS Annual Payment Update (APU), also known as the Market Basket Update, for UPMC hospitals.
Responsible for required data capture for the Joint Commission Accreditation and Certification programs, in addition to the American Heart Association (AHA)-Get with the Guidelines (GWTG)-Stroke programs.
Demonstrates a service-oriented approach by conveying courtesy, respect, enthusiasm, and a positive attitude for work responsibilities? Shows initiative and offers assistance to all department customers and UPMC Health System personnel in the completion of the department's goals.
Patient care issues and inter-departmental services are the priority of this position while protecting confidentiality of all patients related information.
Maintains a strong knowledge base of the CMS Quality Measure Specifications with each new version through continuous maintenance of the glossary, webinars, and continuous education for Inpatient, Outpatient & Electronic data collection.
Maintains a strong knowledge of the current AHA/GWTG Stroke Specifications for Primary/Comprehensive/Acute Stroke Ready Stroke Center facilities.
Able to use Excel and Spreadsheets to filter/sort data for trending and analysis use? Able to review and interpret work lists daily? Independently able to think through and combine technical and clinical documentation requirements
Participates in ongoing assessment of electronic data sources
Able to identify and report EHR changes to Coordinator for team learning and knowledge
Evaluates data abstraction software performance, relating to accurate data capture, to detect potential system issues? Able to perform mathematical calculations as required in specifications
Able to read and interpret CMS Specification Manuals and workflow processes, in addition to other necessary manuals and workflows
Needs to consistently keep up with multiple IP, OP, Stroke, eCQM, other specification manuals with bi-annual/annual revisions and maintain 95%25 accuracy
IP & OP Abstraction: Reviews clinical documentation and extracts the key data elements as defined in the CMS Specifications
eCQM Abstraction: Reviews electronic documentation and electronic fields defined by the CMS electronic Clinical Quality Measure Specifications
Understands and follows complex workflow processes for accurate data capture in the UPMC EHR/Electronic Health Record? Accuracy of the required submitted data is directly related to CMS program revenue and full APU; CMS CDAC/Clinical Data Abstraction Center Audits are done quarterly to validate accuracy? AHA/GWTG Stroke Certification manual with three layers: ASR/Acute Stroke Ready, PSC/Primary Stroke Center, CSTK/Comprehensive Stroke
Reviews clinical documentation and extracts key data elements according to the AHA/GWTG Specifications to maintain certification for Comprehensive, Primary, and Acute Stroke Ready Stroke Centers
As required by The Joint Commission, maintains an 80%25 (95%25 UPMC Team goal) Stroke accuracy rate for internal bi-annual validation audits through applied abstraction skills within the AHA/GWTG Stroke Registry? Accuracy of AHA/GWTG Stroke Abstraction links directly to each UPMC Stroke hospital and their Award of Gold/Bronze/Silver for excellence in patient care and clinical standards (AHA and Joint Commission)
Expert (or can progress to expert) in EHR documentation location for accurate and most appropriate clinical data capture? Understands clinical terminology to accurately apply to date capture
Able to communicate with UPMC Cerner IT/Information Technology regarding clinical data reports
Analyzes and monitors the electronic medical record and identifies the required medical and/or surgical documentation through various electronic systems: MARS, Medipac, billing system, Cerner, HPF, etc., as applicable
Recognizes and reports discrepancies found in the medical record to alert upstream clinical users as appropriate (Data Validation Coordinators, Supervisor, Sr. Manager, Quality Team(s), and Stroke Team(s)? Attends UPMC Departmental and System meetings, training/educational webinars as required.
Reviews, edits, completes PHC4 Error Report as per their Director, Sr. Manager, Supervisor, or Data Validation Coordinator.
Adheres to department productivity standards. Communicates any barriers affecting expected standards and works collaboratively with management team to meet department abstraction goals. Maintains and submits weekly a Daily Productivity Log of activities to the Coordinator/Manager/Supervisor.
Adapts to changes in the work environment and process change, as necessary, and prioritizes work with the assistance of the Data Validation Coordinator, Supervisor, Sr. Manager or Director.
Participates in training and orientation of new employees regarding the electronic record, clinical documentation, abstraction guidelines, and validation processes.
Balance team and individual responsibilities while contributing to building a positive team spirit.