RN QUALITY ABSTRACTOR

Independence Health System•Greensburg, PA

About The Position

Analyzes each acute care inpatient medical record and outpatient medical record for pertinent information, and accurately enters the required information into the database / registry systems, using direct data entry. This includes, but is not limited to, Inpatient Core Measure findings, Outpatient Core Measure findings, Condition Specific National Databases / Registries, Monitors for Special Studies, and Metrics for Focused Studies. References the required source documents of each medical record, to complete accurate abstraction of all possible findings. Modifies collection of findings when required by changes in collection options, and/or software upgrades to the system. Reviews and acts on any upgrade information regarding changes to abstraction requirements and/or guidelines. In the event of system down time, appropriately uses the paper abstraction tool, with accurate data entry to be completed when the system is again available. Maintains at least a 95% accuracy rate for abstraction. Accesses and reviews current specifications / guidelines to assure appropriate application to the specific case scenarios. Assists the Department Coordinator to complete abstraction validation. Resolves any remaining abstraction issues/questions by interaction with other abstractors, the Department Coordinator, Department Manager, Excela Health IT support and/or vendor IT support. Shares information gained from Department Manager or Vendor Support or webinars / release notes with other abstractors. Prioritizes abstraction of inpatient acute care and outpatient medical records according to direction of the Department Manager, in order to achieve internal and external deadlines. Performs any reporting / verification needed to ensure that all records have been completed. Is aware of internal and external deadlines for abstraction and makes every effort to complete any records needed to achieve them. Maintains abstraction productivity levels. Records daily productivity levels and submits reports for each month by the established deadline, to Department Manager. Documents variance from expected on own productivity report. Reviews own individual productivity monthly reports, to assess for trends and patterns and improvement opportunities. Shares/accepts abstraction or process suggestions, to maintain and or increase productivity. Collaborates with the Medical Information Management Department to assure accuracy of demographic and coded information in the medical record. Discusses each case, where the attending physician, surgeon, admission source, or disposition, differs from downloaded information and assures that documented information is correct in both the hospital record, and any system that is the abstractors’ responsibility. Discusses any coding questions, or issues, to assure completeness and accuracy of coded information. Works with IT and Clinical Informatics to maintain data collection systems, including communication of necessary updates to meet regulatory and procedural specifications and active troubleshooting to resolve system issues. Supports and encourages teamwork in abstraction, and in all functions of the Department. Offers assistance to any abstractor and willingly flexes work assignment. Shares abstraction, productivity, or reporting suggestions with other members of the Department. Willingly accepts any offer of assistance, support, or suggestions, to meet Department goals. Understands, at a minimum, the Cerner system and utilizes information available in the EHR to complete abstraction. Verifies auto populated data for accuracy and completes remaining required data fields. Transfers information to complete required data fields, verifying that results for both systems are the same. Collaborates with the multidisciplinary team to identify opportunities to enhance compliance with Quality Measures per evidenced-based guidelines. Assists the clinical team with understanding the documentation necessary to meet requirements for Quality Measures. Concurrently reviews applicable cases to provide real-time monitoring of measure compliance, and notifies designated clinical department staff of any deficits in documentation. Investigates areas of non-compliance with nurse leaders and physicians as needed. Other duties as assigned.

Requirements

Graduate of an accredited Nursing Program required.
Two (2) years clinical nursing experience with use of electronic medical record.
Strong leadership ability, independent thinking and decision-making ability; analytical problem solving skills, sound judgment; excellent oral and written communication skills, must be able to function in a team environment.
Proficient in Microsoft Office applications, including Excel and Word.

Responsibilities

Analyzes each acute care inpatient medical record and outpatient medical record for pertinent information, and accurately enters the required information into the database / registry systems, using direct data entry.
References the required source documents of each medical record, to complete accurate abstraction of all possible findings.
Modifies collection of findings when required by changes in collection options, and/or software upgrades to the system.
Reviews and acts on any upgrade information regarding changes to abstraction requirements and/or guidelines.
In the event of system down time, appropriately uses the paper abstraction tool, with accurate data entry to be completed when the system is again available.
Maintains at least a 95% accuracy rate for abstraction.
Accesses and reviews current specifications / guidelines to assure appropriate application to the specific case scenarios.
Assists the Department Coordinator to complete abstraction validation.
Resolves any remaining abstraction issues/questions by interaction with other abstractors, the Department Coordinator, Department Manager, Excela Health IT support and/or vendor IT support.
Shares information gained from Department Manager or Vendor Support or webinars / release notes with other abstractors.
Prioritizes abstraction of inpatient acute care and outpatient medical records according to direction of the Department Manager, in order to achieve internal and external deadlines.
Performs any reporting / verification needed to ensure that all records have been completed.
Is aware of internal and external deadlines for abstraction and makes every effort to complete any records needed to achieve them.
Maintains abstraction productivity levels.
Records daily productivity levels and submits reports for each month by the established deadline, to Department Manager.
Documents variance from expected on own productivity report.
Reviews own individual productivity monthly reports, to assess for trends and patterns and improvement opportunities.
Shares/accepts abstraction or process suggestions, to maintain and or increase productivity.
Collaborates with the Medical Information Management Department to assure accuracy of demographic and coded information in the medical record.
Discusses each case, where the attending physician, surgeon, admission source, or disposition, differs from downloaded information and assures that documented information is correct in both the hospital record, and any system that is the abstractors’ responsibility.
Discusses any coding questions, or issues, to assure completeness and accuracy of coded information.
Works with IT and Clinical Informatics to maintain data collection systems, including communication of necessary updates to meet regulatory and procedural specifications and active troubleshooting to resolve system issues.
Supports and encourages teamwork in abstraction, and in all functions of the Department.
Offers assistance to any abstractor and willingly flexes work assignment.
Shares abstraction, productivity, or reporting suggestions with other members of the Department.
Willingly accepts any offer of assistance, support, or suggestions, to meet Department goals.
Understands, at a minimum, the Cerner system and utilizes information available in the EHR to complete abstraction.
Verifies auto populated data for accuracy and completes remaining required data fields.
Transfers information to complete required data fields, verifying that results for both systems are the same.
Collaborates with the multidisciplinary team to identify opportunities to enhance compliance with Quality Measures per evidenced-based guidelines.
Assists the clinical team with understanding the documentation necessary to meet requirements for Quality Measures.
Concurrently reviews applicable cases to provide real-time monitoring of measure compliance, and notifies designated clinical department staff of any deficits in documentation.
Investigates areas of non-compliance with nurse leaders and physicians as needed.
Other duties as assigned.