Job Description

JOB SUMMARY:
To abstract clinical data from patient medical records to support the regional needs for chart abstraction, and other local and national studies. To provide the clinical data to the appropriate clinicians to drive improvements in care.

CERTIFICATION & LICENSURE REQUIREMENTS
Registered Professional Nurse (RN) License Must possess and maintain licensure in good standing as a Registered Nurse in the State of Illinois upon hire.

EXPERIENCE REQUIREMENTS
2-3 years of experience in/with clinical nursing preferred or previous abstraction experience as above.

ADDITIONAL REQUIREMENTS

• Use of usual and customary equipment used to perform essential functions of the position.
• Work may occasionally require travel to other Carle facilities/hospitals.
• Required to drive your own vehicle business pruposes.

SKILLS AND KNOWLEDGE
Communication Skills Ability to respond appropriately to customer/co-workerInteraction with a wide variety of peopleMaintain confidential informationAbility to communicate only the facts to recipients or to decline to reveal informationAbility to project a professional, friendly, helpful demeanorTechnical aptitude - ability to learn new systems quicklyComputer Skills Intermediate computer knowledge: Ability to troubleshoot minor problems within a Windows OS, operates within a network environment, uses spreadsheet, database, word processing and internet applications proficiently. Learns new applications without difficulty and is able to aid others in immediate work area with computer questions.MS Office Apps

ESSENTIAL FUNCTIONS:

• Abstraction* Abstracts clinical data in an accurate and timely manner from patient medical records to provide the required data elements for national, local, and other selected studies.* Validates that all data elements are accurately reflected in the patient record; records and tracks data element inaccuracies. This also includes working with physicians, leadership team, and staff to improve the data accuracy.* Works with QIO to ensure data definitions and interpretations are accurate. Stays current on definition changes. * Enters data into web based tools and maintains the timeliness of data abstraction by verifying all records are abstracted.* Coordinates with the Outcomes Coordinator to ensure that all data elements are recorded and educates staff on process/terminology changes. * Tracks and validates that all appropriate patient records have been extracted, works to continually improve accuracy of data elements or missing fields.
• Performance Improvement* Works in conjunction with the Clinical Outcomes Coordinator, facilitates improvement initiatives relative to CMS and Core Measures Projects.* Works closely with physician, leaders and staff as partners to drive improvement.* Makes suggestions for improvement and follow up on changes to assure implemented* Maintains contact with external agencies to assure that Methodist is in compliance and up to date on data collection and requirements.* Provides timely feedback on problematic trends and suggestions for improvement.* Provides education regarding documentation trends and strategies to improve.
• Departmental Support* Supports other projects as needed* Participates in studies where expertise is needed* Participates in team/committee meetings as assigned