Clinical Abstractor - Remote Possible - FT

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Current Bay Area Hospital Employee: If you are a current Bay Area Hospital employee, please apply through the Workday internal career site.

The future looks bright at Bay Area Hospital, and we are always searching for quality people to join our team. We offer a great atmosphere, competitive pay, a wide array of benefits, and many growth opportunities for our employees.

Job Description:

Principal Duties and Responsibilities

• Extracts and abstracts specific clinical data points from medical records, electronic health records (EHRs), and other medical documentation according to established protocols and definitions.
• Reviews abstracted data to ensure its accuracy, consistency, and completeness, often performing quality audits to maintain data integrity.
• Prepares and submits accurate and timely data to various registries or quality reporting systems, such as those related to specific procedures, disease processes, or national measures (e.g., Core Measures).
• Identifies and communicates opportunities and trends based on data findings to improve clinical processes and patient safety.
• Communicates and collaborates with clinical staff, management, and other healthcare professionals to clarify documentation and resolve data discrepancies.
• Aids in the collection and organization of data for research, clinical trials, epidemiological studies, or other data-driven initiatives. 
• Arrays data for presentation in a format that is clear and understandable to audience.
• Maintains an interrater reliability at or above 95%.

Skills and Abilities

• A strong understanding of medical terminology, anatomy, disease processes, and medical coding systems (e.g., ICD-10) is essential.
• Familiarity with Epic EHR, data abstraction software, and data management tools like Microsoft Excel is preferred.
• Excellent attention to detail and a high standard of accuracy are crucial for ensuring the reliability of data.
• Strong analytical and problem-solving skills are needed to review complex records and identify relevant data points.
• The ability to work independently, manage multiple tasks, and maintain organized records is necessary.

Required Education

• RN preferred.
• Association of the Advancement of Automotive Medicine’s Abbreviated Injury Scale (AIS) course required within 6 months of hire.
• Trauma registry course required within 6 months of hire.
• ICD-10 course within 6 months of hire and/or an ICD-10 refresher course every 5 years required.
• Accrue 24 hours of trauma-related CE during the trauma verification cycle (3 years) required.
• Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) within 2 years.

Principal Duties and Responsibilities

• Extracts and abstracts specific clinical data points from medical records, electronic health records (EHRs), and other medical documentation according to established protocols and definitions.
• Reviews abstracted data to ensure its accuracy, consistency, and completeness, often performing quality audits to maintain data integrity.
• Prepares and submits accurate and timely data to various registries or quality reporting systems, such as those related to specific procedures, disease processes, or national measures (e.g., Core Measures).
• Identifies and communicates opportunities and trends based on data findings to improve clinical processes and patient safety.
• Communicates and collaborates with clinical staff, management, and other healthcare professionals to clarify documentation and resolve data discrepancies.
• Aids in the collection and organization of data for research, clinical trials, epidemiological studies, or other data-driven initiatives. 
• Arrays data for presentation in a format that is clear and understandable to audience.
• Maintains an interrater reliability at or above 95%.

Skills and Abilities

• A strong understanding of medical terminology, anatomy, disease processes, and medical coding systems (e.g., ICD-10) is essential.
• Familiarity with Epic EHR, data abstraction software, and data management tools like Microsoft Excel is preferred.
• Excellent attention to detail and a high standard of accuracy are crucial for ensuring the reliability of data.
• Strong analytical and problem-solving skills are needed to review complex records and identify relevant data points.
• The ability to work independently, manage multiple tasks, and maintain organized records is necessary.

Required Education

• RN preferred.
• Association of the Advancement of Automotive Medicine’s Abbreviated Injury Scale (AIS) course required within 6 months of hire.
• Trauma registry course required within 6 months of hire.
• ICD-10 course within 6 months of hire and/or an ICD-10 refresher course every 5 years required.
• Accrue 24 hours of trauma-related CE during the trauma verification cycle (3 years) required.
• Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) within 2 years.

Compensation Grade:

Compensation Grade Profile:

Bay Area Hospital is an Equal Opportunity Employer.

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