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Data Abstractor - Jamestown, NY

  • Job ID: 93603766
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Great Lakes Physician Practice
  • Department: GLPP Administration
  • Location: 15 South Main Street, Jamestown NY 14701
  • Union Position: No
  • Salary Range: $13.69 to $20.84 / hour

Description

Purpose:
Under the direction of the Manager and Data Validation Coordinator, the Data Abstractor will conduct a comprehensive and systematic review of patient medical records. The data abstractor will review clinical documentation to extract key elements from the medical record as required by CMS/Centers for Medicare & Medicaid Service sand other state and Federal agencies, focusing on quality outcomes reporting and CMS Value Based Purchasing. The Data Abstractor will communicate high priority variances to the Data Validation Coordinator, Supervisor and/or Manager for timely resolution within the health system.

Responsibilities:
  • Demonstrates a service-oriented approach to the position by conveying courtesy, respect, enthusiasm and positive attitude for work responsibilities. Show initiative and offer assistance to all department customers and UPMC Health System personnel in the completion of the department's goals. Patient care issues and inter-departmental service are the first priority as a staff member while protecting confidentiality of all patient related information.
  • Analyzes and monitors the electronic medical record and identifies the required medical and/or surgical documentation through various electronic systems: EPIC, MARS, Medipac, Cerner, HPF, etc., where/if applicable. Recognizes and reports discrepancies found in the medical record to alert upstream and downstream users as appropriate. (i.e.: Registration, coding, information systems)
  • Maintains and submits weekly a Daily Productivity Log of activities to the Coordinator/Manager.
  • Adapts to changes in the work environment and process change, as necessary, and be able to prioritize work with the assistance of the Data Validation Coordinator, Supervisor, Manager or Director.
  • Reviews, edits/completes PHC4 Error Report as per their Director, Manager, or Data Validation Coordinator.
  • Maintains a strong knowledge base of the CMS/Core Measure Specifications with each year's new version through continuous maintenance of the glossary, webinars, and continuous education for both Inpatient & Outpatient data collection. Maintains a strong knowledge of the current AHA/GWTG's Stroke Specifications for Primary Stroke Center facilities.
  • Adhere to department productivity standards. Communicate any barriers affecting expected standards and work collaboratively with supervisory team to meet department abstraction goals.
  • Attends UPMC Departmental and System meetings, training/educational webinars as required.
  • Reviews clinical documentation and extracts the key data elements according to rules and regulations as defined in the CMS/Centers for Medicare and Medicaid Specifications Manual . 100% accuracy of this CMS data is critical since the information is directly related to reimbursement for VBP/Value Based Purchasing and full APU reimbursement in regard to quarterly CDAC Audits as applicable
  • Participate in training and orientation of new employees in regards to the electronic record, clinical documentation, abstraction guidelines, and validation processes.
  • Balance team and individual responsibilities while contributing to building a positive team spirit.
  • As required by The Joint Commission, maintains an 80% Stroke accuracy rate for internal bi-annual validation audits through applied abstraction skills within the AHA/GWTG Stroke Registry.
  • Reviews clinical documentation and extracts key data elements according to the AHA/GWTG's Specifications Rules and Regulations to maintain certification for Primary Stroke Centers. As required by The Joint Commission, maintains an 80% Stroke accuracy rate for internal bi-annual validation audits through applied abstraction skills within the AHA/GWTG Stroke Registry.
  • Participates in ongoing assessment of the electronic data sources. Evaluate data abstraction software performance to detect potential system issues.

Qualifications

  • A high school graduate with a minimum of 1-2 years of clinical or core measure abstracting or completion of a certified nurse assistant certificate program. 
  • A strong knowledge in anatomy, physiology, pharmacology and medical terminology is required. 
  • Good written and oral communication and organizational skills is required Must possess high degree of concentration to accurately abstract data from patient records. 
  • Must be detail oriented to assure accuracy of abstracted data. 
  • Must demonstrate ability to work under pressure in a positive team-oriented manner with diplomacy and tact. 
  • Computer skills of Microsoft Office applications and Internet use are required. 
  • Preferred: Cerner or any similar clinical E-record system Knowledge of CMS AMI/PN/HF/SCIP/VTE/Stroke/ED/IMM/OPPS Core Measure abstraction. A graduate of an approved accredited Registered Health Information Technician Program (RHIT or eligible) is preferred.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct