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Role Description

Collaborates with the ECS quality team to accurately review medical records to abstract relevant data for eligible patients utilizing both electronic upload and manual data abstraction of records. Assures electronic data elements are verified for accuracy and assures data entry of manually abstracted data into a clinical registry. The clinical abstractor will work to develop and maintain effective and collaborative team-focused relationships with the ECS quality team, physicians, advanced practice providers, the quality program clinical coordinating center and external partners to drive optimal quality outcomes within ECS.

• Participates in relevant in-person or remote training at assigned sites to develop expertise on tools developed by the clinical registry program center.
• Effectively collaborates with assigned sites to review non-concordant cases and identify and present findings to other key stakeholders.
• Reviews medical records to abstract relevant data for eligible patients utilizing both electronic upload and manual data abstraction of records (abstracting duties may account for up to 90% of the role).
• Assures electronic data are verified for accuracy and assures data entry of manually abstracted data into the clinical registry.
• Utilizes clinical knowledge to examine the electronic medical records of emergency department cases to identify patients eligible for inclusion in the clinical registry.
• Reviews quarterly reports provided by the clinical registry coordinating center to ensure the quality and reliability of data collected.
• Maintains quality control through the identification of suspicious entries, documents and informs the clinical registry coordinating center data auditor and ECS quality leadership of concerning findings.
• Actively participates in audits of data entered into the clinical registry.
• Serves as the first line of contact for assigned sites, assists with the utilization of tools, responds to queries, and addresses concerns.
• Demonstrates the ability to manage fluctuating levels of volume efficiently and prospectively.
• Ensures timely and accurate collection of data and abstraction and demonstrates the ability to meet established case volumes.

Qualifications

• Clinical chart review experience required – one-year minimum
• Working knowledge of medical terminology
• Experience with Microsoft Word, PowerPoint, and Excel
• Detail-oriented with strong organizational, analytic, and problem-solving skills
• Demonstrated exceptional verbal and written communications skills including public speaking
• Must be able to perform in a self-directed manner within a team-focused framework
• Evidence of ability to assess competing priorities, manage workflow and meet operational deadlines in a complex organization with minimal supervision

Requirements

• Bachelor's Degree in a healthcare field or equivalent combination of education and experience [e.g. RN, registered, health information technician (RHIT), research coordinator]
• RN with valid Michigan License or RHIT a graduate from an accredited College or University
• Valid unrestricted driver’s license
• Clinical experience in the ED setting preferred.
• Database data entry and/or management experience
• Quality improvement or patient safety knowledge and experience
• Experience with EPIC documentation system.

Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.

• Regularly required to talk or hear.
• Frequently required to use hands or fingers, handle, or feel objects, tools, or controls.
• Occasionally required to stand, walk, sit, reach with hands and arms, climb or balance, and stoop, kneel, crouch, or crawl.
• Must occasionally lift and/or move up to 25 pounds.
• Specific vision abilities required include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.
• The noise level in the work environment is usually moderate.