Medical Abstractor (Trauma Registry)

JOB SUMMARY

Medical Abstractor supports clinical performance by using specialty registries and databases to abstract data elements from patient records to meet applicable regulatory and safe care practice requirements. The data identified and analyzed by this team member supports ongoing quality initiatives, and is an essential part of providing safe and evidence-based care to our patients, as well as meeting the requirements of regulatory and accrediting entities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Collects specific data elements from the patient electronic medical records (abstracts), validates that the elements align with guidelines, and enters the data elements into a computer database or registry site.
• Performs validation checks for entered data to ensure completeness, accuracy, and timelessness. All data entry deadlines must be met. Maintains information system security and patient confidentiality.
• Maintains communication with customer hospitals, Clinical Quality departments, and other stakeholders as needed, to resolve documentation issues/discrepancies.
• Seeks feedback and performance improvement guidance from Clinical Quality Analyst Educator and Manager.

QUALIFICATION

Required:

• Understanding of medical terminology
• Clinical experience in trauma services, bariatrics, surgery, and cardiology

Education

• Registered Nurse (Trauma Registry)

Preferred

• Experience with medical records data entry and/or review
• Knowledge in RCM (Revenue Cycle Management)