Performs review of complex clinical records to secure data for inclusion into the formal longitudinal registries required by the organization.
Uses appropriate classification and coding systems via computerized software, within the time frames required by local, state and national mandates.
Abstracts high integrity information from the internal medical record and conducts concurrent and or retrospective review of external medical records in order to facilitate complete analysis, monitoring and reporting of quality data.
Performs interoperability and reliability testing and utilizes various data quality monitoring techniques to reconcile and validate information according to registry and internal data quality standards and data dictionaries.
Completes the process for timely submission of data at appropriate intervals to the various advanced and complex disease/procedure specific specialty databases and other registries as required for compliance with membership and professional standards.
Coordinates multi-disciplinary weekly case conferences, preparing notices, summations and submits all required Continuing Professional Development department post-conference documentation for CME.
Develops, performs, and evaluates quality improvement activities for the registries ensuring a percent of abstracted data is physician and peer reviewed on an annual basis.
Performs follow-up of appropriate registry patients over their lifetime as required, maintaining the accuracy and integrity of the data for use in end-results, financial, market, research and quality reporting.
Establishes and maintains effective working relationships with physicians and care management staff working together to compile registry data into meaningful reports/displays and promotes the use and visibility of the information collected.
Prepares and assists with studies for publication, audits, and annual reports in a timely fashion.
Prepares and assists in developing and updating Registry 'Policies and Procedures' on a yearly basis and complies with accrediting agency requirements.
Requirements
Associate degree in health information management or related field (or if working in Cancer Registry, enrollment in Associate degree program and ready to start practicum)
Typically requires 1 year of experience in data collection that includes experiences in coding/abstracting and clinical documentation
Knowledge of medical terminology, anatomy and physiology and pathophysiology
Knowledge of computer applications, computer function and basic statistical methods
Ability to follow detailed coding instructions and specifications with minimal supervision
Ability to work independently with a high degree of accuracy and attention to detail
Ability to communicate well orally and in written format
Ability to travel as needed with exposure to road and weather conditions
Ability to spend extended periods of time (75% of the workday) in sedentary work
Ability to operate all equipment necessary to perform the job.
Ability to secure required credentials according to internal and external requirements for abstraction.
Benefits
Health and welfare benefits such as medical, dental, vision, life, and Short
and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs