Clinical Abstractor - Remote

Clinical Abstractor - Remote Possible - FT

Current Bay Area Hospital Employee:
The future looks bright at Bay Area Hospital, and we are always searching for quality people to join our team. We offer a great atmosphere, competitive pay, a wide array of benefits, and many growth opportunities for our employees.

Time Type: Full time

Hours per Pay Period: 80

Shift: Day Shift

Minimum: $34.96 USD

Maximum: $47.29 USD (This represents the rate for an individual with significant experience in this job)

Department: Accreditation

Clinical Abstractor A Clinical Data Abstractor reviews, analyzes, and summarizes relevant patient information from medical records. The data is then compiled into a structured format for various purposes, including quality improvement initiatives, regulatory reporting, clinical research, and billing.

• 0.5 FTE assigned to Trauma
• Remaining time assigned to Core/Sepsis abstraction

• Extracts and abstracts specific clinical data points from medical records, electronic health records (EHRs), and other medical documentation according to established protocols and definitions.
• Reviews abstracted data to ensure its accuracy, consistency, and completeness, often performing quality audits to maintain data integrity.
• Prepares and submits accurate and timely data to various registries or quality reporting systems, such as those related to specific procedures, disease processes, or national measures (e.g., Core Measures).
• Identifies and communicates opportunities and trends based on data findings to improve clinical processes and patient safety.
• Communicates and collaborates with clinical staff, management, and other healthcare professionals to clarify documentation and resolve data discrepancies.
• Aids in the collection and organization of data for research, clinical trials, epidemiological studies, or other data-driven initiatives.
• Arrays data for presentation in a format that is clear and understandable to audience.
• Maintains an interrater reliability at or above 95%.

• A strong understanding of medical terminology, anatomy, disease processes, and medical coding systems (e.g., ICD-10) is essential.
• Familiarity with Epic EHR, data abstraction software, and data management tools like Microsoft Excel is preferred.
• Excellent attention to detail and a high standard of accuracy are crucial for ensuring the reliability of data.
• Strong analytical and problem-solving skills are needed to review complex records and identify relevant data points.
• The ability to work independently, manage multiple tasks, and maintain organized records is necessary.

• RN preferred.
• Association of the Advancement of Automotive Medicine’s Abbreviated Injury Scale (AIS) course required within 6 months of hire.
• Trauma registry course required within 6 months of hire.
• ICD-10 course within 6 months of hire and/or an ICD-10 refresher course every 5 years required.
• Accrue 24 hours of trauma-related CE during the trauma verification cycle (3 years) required.
• Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) within 2 years.

• Extracts and abstracts specific clinical data points from medical records, electronic health records (EHRs), and other medical documentation according to established protocols and definitions.
• Reviews abstracted data to ensure its accuracy, consistency, and completeness, often performing quality audits to maintain data integrity.
• Prepares and submits accurate and timely data to various registries or quality reporting systems, such as those related to specific procedures, disease processes, or national measures (e.g.,…