EMPLOYEE’S NAME: ________________________

FLSA STATUS:☐ Exempt☒ Non-Exempt

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

Under the direct supervision of the Director of Accreditation Readiness, the Clinical Data Abstractor/Analyst maintains responsibility for interpreting, collecting, validating, analyzing, and reporting data elements as required for participation in assigned regulatory, quality and patient safety initiatives, or programs according to established standards and deadlines.

POSITION EDUCATION/QUALIFICATIONS:

• Associates degree required, Bachelor's degree preferred
• Registered Nurse (RN)/Licensed Vocational Nurse (LVN) preferred
• Ability to work independently and exhibits self-motivation and initiative
• Exhibit excellent customer service skills, strong team alignment, collaboration, and support
• Maintain a strict level of confidentiality and discretion in all aspects of work
• Demonstrate a high standard of accuracy and attention to detail with the ability to maintain a high level of inter-rater reliability
• Computer skills required with proficiency in Microsoft Office Suite
• Demonstrate knowledge of statistical concepts and methods to analyze healthcare data for quality/performance improvement
• Effective written and verbal communication skills are required to work with all levels of hospital personnel from administrators to clinical staff, as well as outside agencies
• Time management and planning skills are necessary to accomplish goals, including the ability to prioritize and manage multiple projects
• Current valid driver’s license required

JOB KNOWLEDGE/EXPERIENCE­:

• Experience with spreadsheets, databases, or at least one registry is desirable
• 2-3 years of clinical abstraction experience preferred
• Demonstrate expertise in the use of data, data validation, and report generation
• Familiar with the electronic health record, medical terminology, billing/documentation practices, and standard healthcare quality concepts preferred
• Demonstrate the ability to effectively navigate external databases and to retrieve and/or input data
• Current and comprehensive knowledge of the methodology and definitions utilized for data abstraction for applicable programs preferred
• Understanding of regulatory/certification/accreditation standards preferred

POSITION RESPONSIBILITIES:

• Read and interpret various components of the medical record and use the information to correctly abstract patient cases
• Enter data into various registries and perform reconciliation and data submission to external organizations as required
• Maintain components data collection system consistent with all pertinent regulatory, accreditation, certification, and organization procedural policies
• Clarify expectations about the scope and purpose of deliverables
• Manage spreadsheets and databases in a manner that support quality improvement across the organization
• Guide the interpretation of the data
• Participate in Joint Commission other regulatory body survey preparation and survey process as assigned
• Communicate abstracted findings, including potential risks and ideas for improvement to senior leadership as assigned
• Schedule appointments and meetings as assigned
• Prepare and edit communications, presentations, and action plans
• Provide strong team support and coordinate with other team members to ensure administrative, department, and project needs are met
• Assist with logistic coordination of special events, such as meetings, conferences, and outreaches
• Attend events in support of departmental leadership and team members
• Perform other duties as assigned

LINES OF RESPONSIBILITY:

1. Accreditation Readiness Supervisor        →        2. Director of Accreditation Readiness & Patient Safety         →        3. Vice President of Quality, Safety, and Accreditations        →       4. Physician Executive

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program, which outlines the Customer Service Principals including: Compassion, Accountability, Respect, Excellence through Knowledge and Safety & Social Conscience.

AGE SPECIFIC:

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit.  The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age.  

AMERICANS WITH DISABILITIES ACT: (ADA): 

A.Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.

The following table provides physical requirements that will be associated with, but not limited to, this position:               

B.Working Conditions:  The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients, and some minimal exposure to noxious smells from cleansing agents. 

C.Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.    

D.Aptitudes:HIGH123456LOW

Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles.  Ability to reason and make judgments. 2

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively.  To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly.              2

Numerical: Ability to perform arithmetic operations quickly and accurately.   2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects.  Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms.  2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines.   3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly.               3

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions.              3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions.              3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli.              3

Color Discrimination:Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color.  To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately.              3

I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

Employee Signature:________________________________Date:____________________