Data Abstractor II per-diem

Quality Management And Performance Improvement

Performs concurrent and retrospective review of clinical documentation to assess compliance with regulatory standards. Completes quality assurance / quality improvement case reviews for medical departmental chairs. Identifies documentation gaps and communicates findings to physicians, other care providers and the Quality Management Team.

Essential Functions:

• Identifies patients in target populations and carries out concurrent and retrospective abstraction for defined elements of care.
• Evaluates the adequacy of medical record documentation in relation to regulatory requirements.
• Maintains the confidentiality of all patient information and reports generated.
• Works in a collaborative manner with patient care unit staff to ensure reliable and consistent information is provided to patients.
• Creates compliance data reports as scheduled or requested.
• Safety Awareness – Fosters a "Culture of Safety" through personal ownership and commitment to a safe environment.
• Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

Non-Essential Functions:

• Other duties as required.
• Understanding of clinical documentation
• Ability to appropriately interpret clinical documentation
• Understanding of clinical care processes
• Excellent communication skills
• Licensed Registered Nurse