Reporting to Clinical Database Manager, the Surgical Services Registry Abstractor is a high-performing individual who is responsible for detailed medical record review and abstraction of clinical data required for quality measures reporting and/or departmental registries. The Surgical Services Registry Abstractor supports patient safety and quality improvement efforts through accurate reporting of compliance to defined metrics and collaborates with departmental team members to facilitate improved patient outcomes. This role provides actionable information to doctors, nurses, and all those who work in a healthcare setting. The job leads directly to improved quality of care, a better patient experience, and increased savings for the healthcare administrative departments.
1. Performs medical record review and abstracts clinical case records to support quality improvement.
2. Manages the overall record retrieval process for collecting numerous complex data elements from individual patient records according to measure specifications and project requirements.
3. Completes all data input, error report analysis and correction, resolution of errors related to data entry, and submission of data. Meets all deadlines. Maintains meticulous records and provides appropriate correspondence.
4. Ensures the integrity and accuracy of information collected and entered into the data collection system and is accountable for their work.
5. Responsible for reporting data and variances to departments and/or committees within the hospital during monthly meetings.
6. Identifies opportunities for performance improvement based on reliable data trending. Makes recommendations based on recognition and analysis of gaps in documentation.
7. Assesses potential problems affecting the data collection process and coordinates follow-up of problem resolution with the team and/or manager.
8. Learns and understands the varied databases and project related terminology. Participates on all educational sessions and/or webinars.
9. Other duties and/or projects as assigned.
10.Adheres to HMH Organizational competencies and standards of behavior.
Education, Knowledge, Skills and Abilities Required:
1. Bachelor's degree.
2. Excellent interpersonal and communication skills with demonstrated ability to work well with all levels of staff.
3. Excellent written and verbal communication skills.
4. Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.
Education, Knowledge, Skills and Abilities Preferred:
1. Bachelor's Degree in Nursing, Informatics or related field.
2. Minimum of 6 months of data abstraction experience.
3. Epic experience.
Licenses and Certifications Required:
1. NJ State Professional Registered Nurse License.
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