POSITION SUMMARY
Under general direction, is responsible for concurrent /retrospective abstracting of clinical data elements from patient records as required by The Joint Commission, PROs, and/or other state/federal regulatory agencies.
Responsible for screening patient care records, utilizing performance improvement indicators approved by the medical staff, and aggregating data for performance improvement reports. May perform other work as required.
POSITION QUALIFICATIONS
Any combination of education and experience that would likely provide the required knowledge and abilities is qualifying. A typical way would be:
Education
Associate Degree in Nursing, BSN preferred
Experience
Minimum of two (2) years experience in a hospital clinical patient care setting. Quality Improvement experience desired but not necessary. Strong computer, analytical, organizational, customer service skills background.
Licensure/Certification
Current Ca. license as a Licensed Vocational Nurse or Registered Nurse preferred
KNOWLEDGE & ABILITIES
Knowledge of:
Regulatory accrediting agency standards and regulations relative to Performance Improvement.
The principles and practices of medical records management; medical terminology including current
procedural terminology and modern office methods.
Local, State and Federal policies, procedures, guidelines, practices, and legislation affecting medical information services.
Confidentiality and HIPAA privacy regulations.
Ability to:
Abstract information from the medical records
Communicate effectively orally and in writing
Prepare correspondence and reports
Analyze complex issues
Establish and maintain effective relations with others
Work under stress, in crisis situations, requiring judgment, action, and focus.
Ensure orientation and focus to details.
Adhere to stringent deadlines.
Work with little to no supervision.
Exhibit strong critical thinking skills.
Strong customer service skills.
Serve as a resource for Administrators, physicians, and managers relative to the peer review process.