About The Position

This position assists the assigned area(s) with data abstraction from medical records for data entry, error correction, data submission, QA (Quality Assurance), and PI (Performance Improvement. Assists with the medical staff peer review process by conducting medical record reviews utilizing established criteria, and assists with other record reviews for data abstraction, trending, analysis, and follow up as applicable to assigned area(s). Our Mission: Quality, compassionate care for all. Our Vision: Reimagine health care through connection, service and innovation. Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.

Requirements

  • Current Montana RN License or a multi-state compact license with authorization to practice nursing within the state of Montana; required.
  • Minimum of three (3) years’ previous work experience in Emergency or Critical Care Nursing required.
  • BLS, ACLS, PALS, TNCC, and ENPC preferred and must successfully obtain within six (6) months of hire.
  • Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and the ability to learn other software as needed.
  • Possess understanding of the confidentiality laws that govern the provider-patient relationship, including but not limited to HIPAA guidelines.
  • Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.
  • Commitment to working in a team environment and maintaining confidentiality as needed.
  • Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.
  • Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

Nice To Haves

  • Bachelor’s degree in nursing (BSN) preferred.
  • TNCC Instructor and/or CEN preferred.
  • Database entry and/or data management experience preferred.

Responsibilities

  • Reviews, collects and/or abstracts patient data from the EMR, medical records, and other source documents for analysis as applicable to assigned area(s).
  • Responsible for accurate, proficient and timely collection / abstraction of data through concurrent and retrospective review of the medical record system as applicable to assigned area(s).
  • Enters data into the electronic database(s) to include data required by regulatory agencies and data used for internal program monitoring, improvement, and special initiatives as applicable to assigned area(s).
  • Assists in data analysis and preparation of reports for committee(s), team reports, and special initiatives, per department protocol and as applicable to assigned area(s).
  • Acts as a resource for other staff and providers as applicable to assigned area(s).
  • Follows through on performance and quality issues identified and works with appropriate stakeholders to apply performance improvement modifications as applicable to assigned area(s).
  • As applicable to assigned area(s); assists stakeholders in maintaining departmental policies and protocols utilizing evidence-based practice; ensures patient care is reflective of current policy, protocol, and/or best practice by reviewing medical records for accuracy and completeness, performance improvement indicators, and audit filters.
  • As applicable to assigned area(s): participates in research activities with stakeholders in areas that effect clinical practice, systems operations, and injury prevention; designs protocols, collects and analyzes data, and distributes findings.
  • As applicable to assigned location: Coordinates Trauma Performance Improvement activities to maintain hospital accreditation as an American College of Surgeons Level III trauma center and State of Montana Area Trauma Hospital.
  • As applicable to assigned location: Assists stakeholders with the Multi-Disciplinary Trauma Committee to improve trauma care, by reviewing selected deaths, complications and sentinel events with objective identification of issues, development of action plans for process improvement, and ensures follow through and loop closure.
  • Analyzes trauma registry, TQIP, and MT state trauma data per department protocol to identity areas for improvement.
  • As applicable to assigned location: Assists in the development, implementation and evaluation of the long-term planning for the Trauma Center.
  • As applicable to assigned location: Functions in a teaching and consultative role for hospital staff, Emergency Medical Services, community, and ancillary health care personnel involved in trauma care.
  • Maintains regular and consistent attendance as scheduled by department leadership.

Benefits

  • PRN employees can participate in a matching 401(k) plan and have access to the Employee Assistance Program.
  • Additionally, they may qualify for hourly differential pay for certain shifts or hours, offering extra compensation based on department-specific scheduling needs.
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