Description
| Abstractor-Clinical Quality Improvement Lead |
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Job Code 22146
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FLSA Status
Exempt |
Job Family
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| Job Summary |
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Responsible for the management and oversight of the centralized clinical data collection and reporting of quality measures, processes information and produces reports. Analyzes data for patterns and trends and identifies areas of opportunity for improvement. Educates the System on quality measure. Assist System Manager-Quality Measures Reporting with eCQM reviews, education, and updates Backup for System Manager -Quality Measures Reporting with managing the CMS Secure Portal and TJC DDS Platform sites for downloading available reports, validating data submissions and required quality measures reporting.
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| Job Responsibilities |
| Job Responsibilities |
- Uses approved software to identify patients for inclusion in the assign measures through application of strict measure inclusion/exclusion criteria.
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- Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data entry into the quality measures software.
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- Completes entry of data into the appropriate software in an accurate and timely manner while ensuring the transmission of completed data.
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- Reviews electronic measures for accuracy and communicates with vendor and BOC regarding required changes/updates
- Review and summarize reports released by CMS for the required reporting programs.
- Assist with tracking required hospital data submissions via CMS IQR Secure Portal and the TJC DDS platform.
- Assist with eCQM measures reporting per CMS/TJC requirements.
- Creates reports for System reporting of quality measures.
- Promotes and applies principles of continuous improvement to improve data abstraction process and data result integrity.
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- Serves as subject matter expert for assigned metrics and serves on appropriate committees as assigned.
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- Communicates effectively with physicians, staff and external entities.
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- Educates hospital staff and physicians regarding quality measure compliance and opportunities.
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- Completes assigned duties.
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- Uses approved software to identify patients for inclusion in the assign measures through application of strict measure inclusion/exclusion criteria.
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| Specifications |
| Experience |
| Description |
Minimum Required |
Preferred/Desired |
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Minimum of 3 years’ experience doing clinical chart review |
Inpatient Clinical experience |
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| Education |
| Description |
Minimum Required |
Preferred/Desired |
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Nursing Degree or HIM associate or higher degree
or equivalent work experience as required for the position. |
Master’s degree, BSN |
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| Training |
| Description |
Minimum Required |
Preferred/Desired |
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Medisolv Chart Abstraction and eCQM Software
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| Special Skills |
| Description |
Minimum Required |
Preferred/Desired |
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Familiar with SQL or Query language. Experience using Microsoft Excel and data visualization tools. Access experience required, being proficient is preferred. Understanding of CMS and TJC reporting requirements |
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| Licensure |
| Description |
Minimum Required |
Preferred/Desired |
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None |
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Reporting Relationships
Does this position formally supervise employees? If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. |
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| Work Environment |
| Functional Demands |
| Label |
Short Description |
Full Description |
| Sedentary |
Very light energy level |
Lift 10lbs. box overhead. Lift and carry 15lbs. Push/pull 20lbs. cart |
| Light |
Morderate engergy level |
Lift and carry 25-35lbs. Push/pull 50-100lbs. (ie. empty bed, stretcher) |
| Medium |
High energy level |
Lift and carry 40-50lbs. Push/pull +/- 150-200lbs. (Patient on bed, stretcher) Lateral transfer 150-200lbs. (ie. Patient) |
| Heavy |
Very high energy level |
Lift over 50lbs. Carry 80lbs. a distance of 30 feet. Push/pull > 200lbs. (ie. Patient on bed, stretcher). Lateral transfer or max assist sit to stand transfer. |
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| Functional Demands Rating |
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| Activity Level Throughout Workday |
| Physical Activity Requirements - Sitting |
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| Physical Activity Requirements - Standing |
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| Physical Activity Requirements - Walking |
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| Physical Activity Requirements - Climbing (e.g., stairs or ladders) |
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| Physical Activity Requirements - Carry objects |
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| Physical Activity Requirements - Push/Pull |
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| Physical Activity Requirements - Twisting |
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| Physical Activity Requirements - Bending |
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| Physical Activity Requirements - Reaching Forward |
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| Physical Activity Requirements - Reaching Overhead |
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| Physical Activity Requirements - Squat/Kneel/Crawl |
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| Physical Activity Requirements - Wrist position deviation |
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| Physical Activity Requirements - Pinching/fine motor activities |
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| Physical Activity Requirements - Keyboard use/repetitive motion |
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| Physical Activity Requirements - Taste or smell |
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| Physical Activity Requirements - Talk or hear |
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| Sensory Requirements |
| Color Discrimination |
Near Vision |
Far Vision |
Depth Perception |
Hearing |
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| Environmental Requirements - Bloodborne Pathogens |
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| Environmental Requirements - Chemical |
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| Environmental Requirements - Airborne Communicable Diseases |
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| Environmental Requirements - Extreme Temperatures |
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| Environmental Requirements - Radiation |
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| Environmental Requirements - Uneven Surfaces or Elevations |
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| Environmental Requirements - Extreme Noise Levels |
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| Environmental Requirements - Dust/Particular Matter |
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Responsible for the management and oversight of the centralized clinical data collection and reporting of quality measures, processes information and produces reports. Analyzes data for patterns and trends and identifies areas of opportunity for improvement. Educates the System on quality measure. Assist System Manager-Quality Measures Reporting with eCQM reviews, education, and updates Backup for System Manager -Quality Measures Reporting with managing the CMS Secure Portal and TJC DDS Platform sites for downloading available reports, validating data submissions and required quality measures reporting.
