Clinical Data Abstractor

Rochester Regional Health

2d•$84,448 - $115,544•Onsite

About The Position

In collaboration with a Clinical Quality Coordinator, the Clinical Data Abstractor is responsible for review and abstraction of inpatient and outpatient core measures, other mandated/publicly reported measures, and data abstraction supporting organizational priorities to help ensure compliance with nationally recognized quality patient care processes and clinical outcomes. Data will be abstracted from electronic and paper based medical records. The position requires attention to detail and the ability to function well under timeline commitments. Provide superior customer service by modeling the Brand Promise and Core Values

Requirements

Associates Degree in Health Information Technology or Associates Degree in allied health, or Nursing required.

Nice To Haves

RHIT or CCS certification
RHIT or CCS certification
Certified Coder Specialist certification preferred.
Metobolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)

Responsibilities

Performs data abstraction of selected medical records within specified time frames for inpatient and outpatient GWTG stroke measures, other mandated/publicly reported stroke measures, Stroke grant milestones and organizational priority initiatives.
Applies data element definitions and abstraction instructions found in the GWTG manual to accomplish timely and accurate review of selected medical records.
Maintains up-to-date knowledge of the applicable Specifications Manuals as well as periodic updates and program guidelines affecting Core/Stroke Measure abstraction and reporting.
Identifies medical records that do not meet specific GWTG guidelines and brings this to the attention of the Stroke team.
Identifies deficiencies in the existing medical record documentation or trended process variances and submit suggestions to the stroke team on ways to improve in processes and/or documentation.
Enters abstraction results into GWTG data and/or other data entry tools as selected by the organization for the project.
Completes review and data entry within assigned timelines.
Works with stroke team to ensure all record abstraction deadlines are met.
Abides by the established security and confidentiality policies and procedures.
Searches the online question and answer databases made available by CMS and the Joint Commission to resolve unclear documentation scenarios and utilizes other abstraction resources such as the SCIP listserv.
Refers abstraction questions to project lead as needed.
Coordination of all aspects of quality assurance activities of the Stroke Center, together with the identification of patients for inclusion in hospital stroke center databases, data abstraction, collection and the demonstration of performance improvement required by, NYSDOH, GWTG, TJC, CMS and GRHF Grant.
Preparation of the Stroke Center Quality and other related reports in consultation with the Stroke Center Team and GRHF Grant requirements.
Maintains regular interaction and communication with Stroke team, clinic staff and other members of the patient care team: problem solving, information gathering, and communication of results and/or needs.
Coordination, data preparation and presentation of the quarterly stroke steering committee meetings, Stroke Grant milestone meetings, and monthly stroke center meetings.
Schedule and oversee all Stroke Center related meetings, as well as the ongoing tasks of these Committees and subcommittees, included but not limited to, recording and distributing minutes and meeting materials; preparing and distributing of agendas and related documents; maintaining Stroke Center Policies and Procedures.
Identifies 100 percent of metabolic and bariatric surgery patients for inclusion in the MBSAQIP data registry.
Collects preoperative, intraoperative, 30-day postoperative, and long-term (six month and annual thereafter) follow-up data components for the program through the effective utilization of the hospital medical record systems and through a coordinated effort with individual surgeon office staff.
Identifies streamlining and process improvement opportunities in the data collection process.
Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the program.
Utilizes software applications for data collection and analysis.
Responsible for the accurate, complete and timely entry of data into the program’s database.
Establishes effective working relationships with members of the hospital community, especially staff in the surgery, medicine, nursing, medical records, and information systems departments and individual bariatric surgeons’ offices whose support is necessary for the management and success of the program.
Serves as an educational resource on the MBSAQIP Data Registry Platform for internal and external audiences by developing educational material and delivering presentations.
Participate in at least two MBS Committee meetings annually.
Identifies and includes eligible patients for required cardiac registries, including STS Adult Cardiac Surgery, ACC/TVT (TAVR/Structural Heart), and NCDR CathPCI, following NYS DOH, CMS, and national reporting guidelines.
Performs timely, accurate abstraction of pre‑procedure, intra‑procedure, and post‑procedure data for cardiac surgery, PCI, and structural heart programs using current registry manuals and specifications.
Monitors documentation for completeness, identifies gaps or clarification needs, and partners with cardiology and cardiac surgery teams to support documentation and process improvement.
Ensures all data submissions (quarterly/semiannual) meet accuracy and upload deadlines for STS, NCDR, and TVT Registry, including responding to data quality checks.
Prepares data for cardiology quality meetings (PCI, Structural Heart, STS review) and assists with performance improvement efforts, trend analysis, and required reports.
Maintains regular communication with cardiology, cardiothoracic surgery, cath lab, and structural heart program staff on data needs, documentation expectations, and quality performance.