RN Clinical Data Abstractor - Quality Outcomes

PeaceHealth is seeking a RN Clinical Data Abstractor - Quality Outcomes for a Full Time, 1.00 FTE, Day position.

The salary range for this job opening at PeaceHealth is $46.27 - $69.41. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc.

Job Summary

Responsible for abstracting and/or auditing a large volume of clinical case records, data, or other information within established deadlines in support of PeaceHealth's quality assessment and performance improvement program and compliance with regulatory and accreditation requirements. Applies clinical training, knowledge and clinical experience in the review of moderate to highly complex clinical information from individual patient records and other sources to abstract data elements for clinical registries and to ensure compliance with standards of care, policies and procedures, regulations or accreditation requirements. Produce reports addressing variances from established standards, and identify significant data trends, outlier values or unusual data for additional review by physicians, clinical value improvement staff and/or leadership. Responsible for the integrity of the reported data.

Essential Functions

• Manages, schedules and receives patient records for abstracting from multiple PeaceHealth hospitals; abstracts moderate to highly complex clinical data using established definitions and abstraction guidelines; maintains an abstracting volume to meet internal and external reporting deadlines.
• Enters abstracted data into the appropriate registry or third-party vendor software within the established deadlines for data submission.
• Conducts or coordinates audits of patient records or other information to support the quality assurance and performance improvement program in each PeaceHealth community and evaluate compliance with established standards and/or regulatory and accreditation requirements.
• Identifies potential areas of concern/interest; interprets actual trends and develops reports that display variances from established standards of care or regulatory standards; summarizes findings and draws conclusions; maintains ongoing variance reports and communicates findings to provider, clinical value improvement caregivers and/or leadership in a timely manner; works with providers to interpret data trends and/or variances.
• Maintains accuracy in abstraction by following published guidelines and abstraction specifications; maintain accuracy and integrity of audit information by following standards and guidelines; facilitates and participates in quality assurance audits of abstracted/audited data to ensure a high level of inter-rater reliability among the clinical data abstractor team and achievement of acceptable validation results from external audits.
• Creates case finding or internal audit reports in an acceptable format for additional review by providers, clinical value improvement caregivers and/or leadership.
• Participates in teleconferences, webinars, and/or onsite educational opportunities. Shares knowledge with clinical value improvement caregivers and teams.
• Creates and supports an environment that fosters and supports teamwork; works collaboratively with providers, clinical value improvement caregivers, health information management, and operational leaders.
• Participates in team or committee meetings to present and discuss data and identify trends as appropriate.
• Performs other duties as assigned.

Qualifications

Education

• Associate Degree Required: Nursing
• Bachelor's Degree Preferred: Nursing

Experience

• Minimum of 3 years Required: clinical experience in an acute care hospital or care management and/or hospital insurance case management experience
• Preferred: Experience in surgery, inpatient care and emergency services, or an Advanced Nurse Practitioner degree
• Preferred: Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity

Credentials

• Required: Registered Nurse in state of practice
• Preferred: Certified Professional in Healthcare Quality

Skills

• Advanced knowledge of medical terminology, anatomy and physiology and understanding of disease processes, pharmaceuticals, and diagnostic studies (Required)
• Strong organization, analysis, software aptitude, and communication skills (both written & verbal) (Required)
• Proficient skills in database management, spreadsheets, word processing, graphs and presentations (Required)
• Proficient with MS Office applications (Required)
• Demonstrated experience working successfully with physicians and clinicians (Required)
• Current knowledge of regulatory and accreditation requirements related to data abstraction and reporting, quality assurance, performance improvement and required measurement systems (Required)
• Knowledge of current clinical practice standards as demonstrated by recent clinical experience or adequate continuing education (Required)

Working Conditions

Lifting

• Consistently operates computer and other office equipment.
• Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.
• Sedentary work.

Environmental Conditions

• Predominantly operates in an office environment.
• Some time spent on site in medical/hospital setting.

Mental/Visual

• Ability to communicate and exchange accurate information.
• The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.

PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.