NSQIP / MBSAQIP Surgical Clinical Reviewer Job Description

Division/Location: Direct Difference – Support of contracted facility as designated

Skill Set: Health Data Analyst

Job Summary/Purpose:

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. Results of audits and identified trends are reviewed with Clinical Nurse Specialists, unit-assigned clinical staff, Performance Improvement staff, and physician quality task forces.

Minimum Qualifications:

Education: Graduation from an accredited school of nursing as an LPN or an RN
Experience: At least 3 years of acute care nursing experience
Licensure: Must be licensed by State Board of Nursing


  • Must be currently certified as a National Surgical Quality Improvement Program (NSQIP) and/or Metabolic and Bariatric Surgical Clinical Reviewer (MBSCR) or complete certification upon request.
  • Must maintain NSQIP / MBSCR certification thru annual competency examination as per program requirements.
  • Must possess knowledge of anatomy and disease processes.
  • Must be computer literate and knowledgeable in spreadsheet software, database programs, Microsoft Office software.
  • Requires flexibility in work schedule.

Job Description:

The NSQIP / MBSAQIP Data Abstractor’s key responsibility is to collect and submit accurate, complete, and timely data to the NSQIP / MBSAQIP Data Registry Platform. This task is accomplished through high-quality data compilation, documentation, and entry of 100 percent of included surgical and metabolic and bariatric procedures performed at the Center into the NSQIP / MBSAQIP Data Registry Platform.

Specific Job Responsibilities and Capabilities:

Data Collection and Reporting:

  • Reviews 100 percent of metabolic and bariatric surgery patients for inclusion in the NSQIP / MBSAQIP data registry as identified by the facility.
  • Collects preoperative, intraoperative, and 30-day postoperative follow-up data components for the program through the effective utilization of the hospital medical record systems.
  • (MBSAQIP only): If contracted, collects long term follow-up data components (six months and annual thereafter) for the program also thru the effective utilization of the hospital medical record system and collaboration with the surgeon office staff to ensure compliance with MBSAQIP program follow up requirements.
  • Responsible for the accurate, complete, and timely entry of data into the program’s database.
  • Identifies streamlining 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 NSQIP / MBSAQIP Data Registry Platform for internal and external audiences as needed.

Primary Requirements

  • Successfully completes the MBSCR Online Training Program.
  • 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 such as ASMBS, ACS NSQIP, or ACS Clinical Congress.

Data Registry

Direct Difference supports accurate, reliable data abstraction of clinical data registries. Our commitment is excellence.

Core Measures &
Data Abstraction

We have been abstracting and supporting core measure abstraction since its inception. We offer unparalleled expertise.

Medical Records
Research/Peer Review

Ask us about our customized processes for OPPE and FPPE reviews for Emergency, Medical, Surgical, Anesthesia Services.

Technology & Software

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