Abstracts and audits complex clinical data from patient records for clinical registries and quality standards. Enters registry data, identifies variances and trends, supports quality assurance audits, communicates findings to clinical and quality leadership, and conducts patient or provider follow-up. The role requires an Arizona or compact-state RN license, acute-care hospital experience, and remote work from Arizona.
Primary City/State:
Virtual ArizonaCategory:
Health InformationShift:
DayDepartment:
Quality Improvement DivisionMonday - Friday 8:00am - 4:30pm - remote position.
Virtual Training.
Must reside in the state of Arizona.
Great care starts with great people. (Like you.)
At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.
Responsibilities:
JOB SUMMARY
The Clinical Data Abstractor II abstracts and/or audits clinical records, data or other information. The Clinical Data Abstractor II applies clinical training, knowledge and 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. In addition, the Clinical Data Abstractor II will identify and report variances from established guidelines, significant data trends, outlier values or unusual data for additional review by physicians, operational and/or quality leadership.
ESSENTIAL FUNCTIONS
- Utilizes clinical training, knowledge, and experience to abstract/audit moderate to highly complex clinical data; Maintains accuracy in abstraction/audit by following published guidelines, abstraction specifications and/or other established standards; Enters data elements or audit findings into registry software and/or other data collection tools or software within established deadlines; Maintains established productivity standards
- Maintains competency in measure and/or registry specifications, definitions, and protocols for work assigned by participating in teleconferences, webinars, conferences, and reviewing updated documentation.
- Identifies potential areas of concern/interest; summarizes findings and draws conclusions; maintains ongoing variance reports and communicates findings to clinical data abstractor lead and/or director in a timely manner.
- Established effective working relationships with key stakeholders, teams, and committees; attends meetings as appropriate to disseminate findings, provide education, and answer questions.
- Contacts patients, families, and/or provider outpatient clinics via telephone and/or written communications postoperatively for the purpose of identifying clinical outcomes and completing required registry follow-up documentation.
- 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.
- Performs other duties as assigned.
EDUCATION
- Associates Nursing Required
- Bachelors Nursing Preferred
EXPERIENCE
- 3 years experience working in acute care hospital setting. Required
- 1 year auditing or abstraction experience. Preferred
- 2 years experience in abstracting CMS Core Measures or Clinical Outcomes Registries (NSQIP, STS, ACC, VON NICU, GWTG, etc.) Preferred
- Other Acute care experience in surgery, cardiac, emergency or critical care. Preferred
LICENSES AND CERTIFICATIONS
- Registered Nurse (RN) - License Valid State of Arizona or compact state Registered Nurse license. Required
- Candidates hired and assigned to the ACS NSQIP or MBSAQIP registry must complete surgical case reviewer training/certification within 90-days of hire (training provided/paid by organization) 90 Days Required
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