Clinical Data Abstractor

Yale-New Haven Health New Haven , CT 06501

Posted 2 months ago

Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The clinical data specialist is responsible for obtaining and verifying clinical information and data to support clinical quality performance measurement and improvement throughout YNHHS. The incumbent will serve as data abstractor and liaison in YNHHS measurement projects and registries. The incumbent will retrieve and enter data using the data collection process according to measure specifications and project requirements.

The incumbent will take personal responsibility for the data collection process and will work with administrator, physician, nurses, and associated staff to ensure efficient and accurate data collection and reporting . EEO/AA/Disability/Veteran Responsibilities 1. Collects/abstracts relevant data associated with clinical quality project (s) based on the measure specifications and guidelines provided by government, regulatory agencies, registries or vendor. 2. Responsible for information processing including generation of data abstraction tools, data entry routines and monthly reports. 3.

Ensures the integrity and accuracy of information collected and entered into the data collection system and is accountable for their work. 4. Assesses potential problems affecting the data collection process and coordinates follow -up of problem resolution with team and/or manager. 5. Participates in regulatory, government or vendor audits as assigned 6.

Complies with HIPAA guidelines for security and confidentiality of data and information. 7. Provides correspondence and/or telephone follow-up and attends in-person meetings for selected groups as needed. 8. Responsible for maintaining and improving knowledge base relevant to assigned project(s) through attending in-services, seminars, meetings, and through reading relevant literature. 9.

Maintains flexible work schedule to meet the needs of a given project. 10. Travel to YNHHS member facilities and for meetings that may be required. 11. Provides oversight for periodic case reviews and reports with hospital contacts to resolve questions, identify risk areas, documentation trends and communicate changes in measure requirements 12. For Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Reviewers Only: 12.1 Data collection: - 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 .

  • Helps identify 100 percent of metabolic and bariatric surgery patients for inclusion in the MBSAQIP data registry.

  • Participates in data compilation for audits and (re)accreditation or site visits

  • Establishes effective working relationships with members of the individual bariatric surgeons ' offices and hospital community whose support is necessary for the management and success of the program. Qualifications EDUCATION Registered Nurse with Bachelors degree preferred EXPERIENCE At least Five (5) Years' experience in healthcare, public health, or related field required.

    Clinical experience : Med/Surg or ICU experience preferred. Two to three years experience in working with systems issues such as case management or utilization review is preferred. Experience with structured electronic medical record abstraction is preferred.

    EPIC experience preferred. Working knowledge of entering clinical information into computerized database is preferred LICENSURE RN licensure required SPECIAL SKILLS Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters with the entire hospital team.

    Comprehensive understanding in use of medical record to extract data . Working knowledge of third party and prospective payment systems. Computer PC literacy required. Must be able to work collaboratively and independently.

    Must be flexible with responsibilities in order to meet departmental needs. Must have keen eye to detail. Additional Information YNHHS Requisition ID 36459

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Clinical Data Abstractor

Yale-New Haven Health