Data Abstractor II per-diem

Job Description Summary

Performs concurrent and retrospective review of clinical documentation to assess compliance with regulatory standards. Completes quality assurance / quality improvement case reviews for medical departmental chairs. Identifies documentation gaps and communicates findings to physicians, other care providers and the Quality Management Team.

Job Description

ESSENTIAL FUNCTIONS Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions that the person in the job is held accountable for. Following are the essential functions of the job. * Use this to denote if a function does not provide opportunity to perform beyond "Meets Expectations" 1. Identifies patients in target populations and carries out concurrent and retrospective abstraction for defined elements of care. a. Identifies documentation gaps and communicates them to physicians, other care providers and Quality Management Team. b. Documents information and tracks performance outliers using standard work templates. c. If assigned, assists in providing feedback on documentation adequacy to involved clinicians. d. Reviews identified inpatient charts before discharge. e. Participates in improvement teams as requested. 2. Evaluates the adequacy of medical record documentation in relation to regulatory requirements. Notifies Quality Management Team of significant, recurring missing or suboptimal documentation. 3. Maintains the confidentiality of all patient information and reports generated. a. Limits discussion of patient information or reported data to individuals with a need to know. b. Limits discussion of data adequacy issues to appropriate staff. c. Conducts above discussion in areas appropriate to maintaining confidentiality. 4. Works in a collaborative manner with patient care unit staff to ensure reliable and consistent information is provided to patients. a. Informs clinical care givers of needed interventions or documentation in a collaborative manner. b. Assists clinical care givers in understanding the need for selected interventions or documentation. 5. Creates compliance data reports as scheduled or requested a. Provides other reports as results warrant or as requested 6. Safety Awareness – Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. a. Understands the JCAHO National Patient Safety Goals and their impact on role. b. Demonstrates knowledge of organizational safety priorities and their department specific application. c. Understands methods of reporting safety concerns and improvement opportunities. d. Understands role/responsibility during hospital “Codes.: e. Knows where to find pertinent material safety data sheets (MSDS). f. Successfully answers safety questions in annual mandatory education program. ESSENTIAL FUNCTIONS (Cont.) I. Technology and Learning a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization. b. Embraces technological advances that allow us to communicate information effectively and efficiently based on role. NON-ESSENTIAL FUNCTIONS Non-essential functions are those tasks, duties and responsibilities that are not critical to the performance of the job. Following are non-essential functions of the job, along with the corresponding performance standards. 1. Other duties as required. Understanding of clinical documentation Ability to appropriately interpret clinical documentation Understanding of clinical care processes Excellent communication skills Licensed Registered Nurse