Job Description

Job Summary

The Core Measures Abstractor is responsible for the review and abstraction of patient medical records for quality indicators and hospital performance metrics. This role involves data collection, entry, and analysis to identify trends and quality issues, supporting hospital improvement initiatives and compliance with established standards.

Essential Functions

• Reviews and abstracts data from patient medical records in alignment with established quality measures, including JCAHO Core Measures, mortality reviews, and quality of care standards.
• Enters abstracted data into tracking systems, ensuring accuracy and consistency to support quality improvement initiatives and regulatory reporting.
• Identifies and reports documentation deficiencies, potential quality concerns, or trends to the supervisor or director.
• Coordinates with medical and hospital staff to facilitate the use of data resources for quality improvement efforts and compliance with performance metrics.
• Maintains secure and confidential records of cases reviewed, and compiles reports for quality committees and hospital leadership as needed.
• Ensures compliance with hospital policies regarding data confidentiality and the protection of patient information.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• Associate Degree in Health Information Management, Nursing, or a related field required
• Bachelor's Degree in Nursing, Health Information Management, or a related healthcare field preferred
• 0-2 years of experience in medical records review, quality data abstraction, or a related field in a healthcare setting required
• Experience in quality measures abstraction and familiarity with JCAHO Core Measures preferred

Knowledge, Skills and Abilities

• Proficient in medical terminology and an understanding of clinical documentation and quality measures.
• Familiarity with hospital electronic medical record (EMR) systems and quality data tracking software.
• Strong attention to detail and analytical skills for accurate data abstraction and trend identification.
• Excellent communication skills for collaborating with clinical staff and reporting findings to supervisors.
• Ability to work independently and maintain confidentiality of sensitive patient information.

Licenses and Certifications

• RHIT - Registered Health Information Technician preferred or
• RHIA - Registered Health Information Administrator preferred or
• Certified Clinical Documentation Specialist (CCDS) preferred or
• CPHQ - Certified Professional in Healthcare Quality preferred