CHI Health
Location
Omaha, NE | United States
Job description
Overview
This position works independently and abstracts a large volume of clinical case records within published deadlines for continuous reporting to internal and external quality and/or patient safety initiatives including but not limited to CommonSpirit Health, Catholic Health Initiatives (CHI), Dignity Health, Centers for Medicare and Medicaid (CMS), The Joint Commission (TJC) and other entities as required. The work involves managing the overall record retrieval process for abstracting required data, collecting numerous complex data elements from individual patient records, entering data into the applicable database while ensuring the integrity and timeliness of the electronic data transmitted to the established national database or entity. Abstractor, Clinical License are required to understand complex data
specifications and methodologies underlying initiatives and must possess a significant understanding of the care processes and related documentation and coding processes for each of the clinical focus areas worked on.
Accurate, timely data abstraction for support of the CMS Hospital Inpatient and Outpatient Quality Reporting Program
measures, TJC Core Measures, Get with the Guidelines, and/or other Clinical Quality and Patient Safety measures
Keeping constantly abreast of changes in data definitions and measure specifications. Maintains current knowledge of
regulatory changes pertaining to quality performance improvement activities and reporting requirements.
Apply all concepts of the nursing and other care processes, such as identification of disease, facilitation of healing,
health promotion, illness presentation and patient care delivery to each task and patient review
Informs hospital staff of variances as appropriate and updates supervisor/interested parties when significant trends
appear in the data. Identification of potentially non-compliant cases requiring additional review. Proactively identifying
risks to success with in focus areas being measured and communicating to appropriate personnel Interaction and
detailed review of abstracted data with Clinical Programs, Quality Management, Patient Safety, etc.
Collaboration with quality improvement team members and other key stakeholders in data accuracy and improvement
efforts. Serving as an expert resource for key stakeholders
Performs other related duties as needed / required.
Licensed Registered Nurse (BSN preferred) Licensed Clinical Pharmacist or other Licensed Clinical Staff able to perform medical and/or surgical Registry Abstraction
Maintain current licensure
Demonstrated clinical experience related to a wide variety of patient populations and care delivery models
Knowledge of clinical practices care processes and procedures
Specialized knowledge of Medical Records and Health Information Management practices and documentation including familiarity with patient charts disease classification and coding.
Competency with extraction of information from health records organization and management of information and analysis of information.
Experience with data abstraction.
Knowledge of Joint Commission Core Measures and CMS Hospital Inpatient and Outpatient Quality Reporting Program.
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