Specific Duties and Responsibilities
Conducts concurrent chart abstractions following current abstraction guidelines for CMS, Joint Commission, national data registries (i.e. NHSN) and other internal and external regulatory agencies with a high degree of accuracy of information entered.
Performs concurrent and retrospective case reviews based on generic screens, clinical indicators, focused studies, physician or outcome issues and occurrence reporting.
Completes Quality Core Measure clinical chart abstractions with minimal supervision and direction and with accuracy. Responsible for providing unit specific data as per units QI requirements and regulations.
Works closely with directors and managers to understand departmental data sets and provide reports on regular basis.
Effectively utilizes online data abstraction tools and reports, Joint Commission and CMS abstraction resources and other internal and external databases.
Identifies opportunities for performance improvement based on data trending; recognizing and analyzing undesirable patterns or trends in performance.
Tracks outliers and provides data reports and other information related to specific metrics to facilitate analysis and follow-up for improving Quality Core Measure compliance.
Assists in finalizing data for submission to external regulatory agencies.
Maintains and prepares the Ongoing and Focus Professional Practice Evaluations (OPPE and FPPE) for the hospital and Medical Staff Peer Review meetings.
Engages in activities and identify opportunities to improve the quality of care by working with physicians, nurses and other clinicians to develop strategies to improved performance.
Serves as an educational resource on the Quality Core Measures methodology and algorithms for internal and external audiences by developing educational materials and delivering presentations.
Clinical knowledge of assigned clinical conditions and physiological systems to discern the impact of specific indicators on outcomes and to identify potential gaps in clinical care processes.
Works in conjunction with the hospital’s Quality Improvement, Patient Safety, Infection Control and other assigned committees.
Ability to interact with all members of the healthcare team, administrative staff and others in a professional and courteous manner.
Ability to build relationships and gain alignment for clinical support from superiors and peers.
Other duties as assigned.