Chart Abstractor Level II

Marketing Statement

Woodhull Medical and Mental Health Center is attuned to the healthcare issues that matter to the people of North Brooklyn. Woodhull focuses on preventing disease and promoting healthy lifestyles by reaching out to the community at various convenient locations.

At NYC Health + Hospitals, our mission is to deliver high‑quality care health services, without exception. Every employee takes a person‑centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Under direction, provides ongoing System‑wide medical record reviews/data abstraction and participates in the data validation process for quality of care indicators, as defined by regulatory agencies and quality programs. Ensures optimal utilization of resources, service delivery and compliance with NYC Health + Hospitals, health care settings, and all relevant regulatory policies, procedures, and standards of care for better outcomes and improved patient experience.

May be required to train or orient new members of the team. All personnel perform related work.

At a more difficult and responsible level, performs the duties of Assignment Level I:

• Performs chart abstraction, clinical data compilation and analysis to generate reports and view System‑wide trends to share with quality and clinical leads at the health care setting and System‑level.
• Conducts clinical data validation review for electronic clinical quality measures (eCQMs) and internal quality assurance activities to ensure data accuracy and consistency across all data measures.
• Maintains, coordinates, and monitors clinical data collection and analysis on performance improvement opportunities, patient safety and compliance issues related to quality core measures; assists in the development of standardized processes to efficiently collect and analyze data.
• Acts as a liaison by providing feedback to and collaborating regularly with multiple stakeholders at the health care setting and System‑level, including but not limited to Clinical Council physicians, Nursing leaders and Department and unit staff, and other stakeholders.
• Conducts concurrent chart reviews for programs requiring time‑sensitive data abstraction, including but not limited to sepsis; provides close to real‑time feedback to clinical and non‑clinical stakeholders.
• Responsible for the accurate and timely entry of data into program database portals, and meets the caseload accrual requirement protocol.
• Participates in clinical audits conducted by regulatory agencies and governing bodies. Interacts with regulatory agencies for clarification and interpretation of applicable regulations.
• Conducts literature review of Patient Safety and Performance Improvement processes and communicates appropriate information to the designated quality and health care setting department staff on current regulations and new developments and trends.
• Works with clinical, site level quality and other appropriate staff to assist with timely and accurate clinical data submission and developing strategies and corrective actions to enhance continuous compliance with measures.
• Performs other related work, as assigned.

In addition to performing the duties of Assignment Level I at a more difficult and responsible level, as described above, also performs the following:

• Contributes to the strategic planning and quality improvement initiatives and activities related to chart abstraction, clinical data validation, and quality metric reporting, by providing expert‑level abstraction and assessment, and effective recommendations or solutions for improvement.
• Leads and coordinates team meetings to discuss processes of chart abstraction, clinical data analysis and validation; identifies standardization and improvement needs within internal department.
• Assists in the development or revision of policies, procedures, and guidelines to support best practices for chart abstraction, clinical data validation, and quality reporting and ensures all compliance…