CMS SEPSIS Measures Abstractor Job Description
Division/Location: Direct Difference – Support of contracted facility as designated
Skill Set: Health Data Analyst
Job Summary/Purpose: CMS: Core Measures SEPSIS and ASSOCIATED POPULATION MEASURES
Performs clinical auditing and data abstraction of patient records in support of contracted facility’s clinical process improvement and patient safety initiatives associated with participation in various quality data reporting systems. Results of audits and identified trends are reviewed with Clinical Nurse Specialists, unit-assigned clinical staff, Performance Improvement staff, and physician quality task forces.
Education: Graduation from an accredited school of nursing as an LPN or an RN
Experience: Minimum 2 years’ recent experience clinical data abstraction of specified measure/registry Core Measures :Inpatient Stroke, Outpatient Stroke and related Measures.
Licensure: Must be licensed by State Board of Nursing
*Education and licensure requirement may be waived if 3+ years’ experience clinical data abstraction with outside validation results > 95%.
- Must maintain competency and knowledge of data definitions, current version and reporting guidelines
- Must possess knowledge of anatomy and disease processes.
- Must be computer literate and knowledgeable in spreadsheet software, database programs, Microsoft Office software.
- Must be self-directed to troubleshoot computer issues associated with mapping network drives, installing software, and connecting to contracted facility thru remote access (VM Ware, AnyConnect, etc.)
- Requires flexibility in work schedule.
The Data Abstractor’s key responsibility is to collect and submit accurate, complete, and timely data to the specific registry or measure data repository. This task is accomplished through high-quality data compilation, documentation, and data entry of identified procedures performed and/or disease process treatment at the Contracted Facility into the associated registry/vendor tool platform.
Specific Job Responsibilities and Capabilities:
Data Collection and Reporting:
- Reviews patients for inclusion in the specific data measure/registry as identified by the facility.
- Collect related clinical data (hospital presentation, treatment, preoperative, intraoperative, and 30-day postoperative follow-up data components) as defined by the measure/registry steward through efficient utilization of the hospital medical record systems.
- Identifies streamlining, documentation, and process improvement opportunities in the data collection process.
- Responsible for the accurate, complete and timely entry of data into the program’s database.
- Maintain accuracy threshold of greater than or equal to 95 percent.
- Work Effectively with Hospital and Individual Surgeon Office Staff
- Serves as an educational resource on the specific measure/registry for internal and external audiences as needed.
- Communicate clearly any data documentation needs to support accurate and high reliable data collection and reporting.
- Preferred Related Support
- Participates in program teleconferences.
- Participates in data compilation for audits and (re)accreditation or site visits. Periodically attends voluntary in-person professional development seminars offered at various annual meetings related to experienced data measure/registry set.