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NYC Health + Hospitals · 13 hours ago

Chart Abstractor Level II

Brooklyn, NY

Full-time

Onsite

Mid, Senior Level

3+ years exp

NYC Health + Hospitals is committed to delivering high-quality care health services. The Chart Abstractor Level II role involves performing medical record reviews and data abstraction to ensure compliance with quality care indicators and participating in quality improvement initiatives.

Health CareHome Health CareHospitalMedicalNursing and Residential Care

Responsibilities

Performs chart abstraction, clinical data compilation and analysis to generate reports and view System-wide trends to share with quality and clinical leads at the health care setting and System-level

Conducts clinical data validation review for electronic clinical quality measures (eCQMs) and internal quality assurance activities to ensure data accuracy and consistency across all data measures

Maintains, coordinates, and monitors clinical data collection and analysis on performance improvement opportunities, patient safety and compliance issues related to quality core measures; assists in the development of standardized processes to efficiently collect and analyze data

Acts as a liaison by providing feedback to and collaborating regularly with multiple stakeholders at the health care setting and System-level, including but not limited to Clinical Council physicians, Nursing leaders and Department and unit staff, and other stakeholders

Conducts concurrent chart reviews for programs requiring time-sensitive data abstraction, including but not limited to sepsis; provides close to real-time feedback to clinical and non-clinical stakeholders

Responsible for the accurate and timely entry of data into program database portals, and meets the caseload accrual requirement protocol

Participates in clinical audits conducted by regulatory agencies and governing bodies. Interacts with regulatory agencies for clarification and interpretation of applicable regulations

Conducts literature review of Patient Safety and Performance Improvement processes and communicates appropriate information to the designated quality and health care setting department staff on current regulations and new developments and trends

Works with clinical, site level quality and other appropriate staff to assist with timely and accurate clinical data submission and developing strategies and corrective actions to enhance continuous compliance with measures

Contributes to the strategic planning and quality improvement initiatives and activities related to chart abstraction, clinical data validation, and quality metric reporting, by providing expert-level abstraction and assessment, and effective recommendations or solutions for improvement

Leads and coordinates team meetings to discuss processes of chart abstraction, clinical data analysis and validation; identifies standardization and improvement needs within internal department

Assists in the development or revision of policies, procedures, and guidelines to support best practices for chart abstraction, clinical data validation, and quality reporting and ensures all compliance and regulatory standards are met

Supports clinical, quality management and other staff with timely and accurate clinical data submissions to external quality performance measurement platforms. Abstractions may include, but are not limited to measures required for submission to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), New York State Department of Health (NYSDOH), Leapfrog and other regulatory agencies

Serves as lead Chart Abstractor, providing guidance to other Chart Abstractors and acts as an educational resource by developing training materials and delivering presentations. Handles more difficult cases, as needed

Supervises and/or reviews work of Assignment Level I

Qualification

Registered Nurse (RN)Chart AbstractionClinical Data ValidationQuality Metric ReportingAmerican College of Surgeons SoftwareSupervisory SkillsTeam CoordinationCommunication Skills

Required

A valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED); and Bachelor of Science in Nursing degree from an accredited college or university; and one (1) year of chart abstraction experience or two (2) years of medical records review or utilization and case management experience

Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issued by the NYSED; and one (1) year of experience, as described in '1' above

Valid New York State license and current registration to practice as a Physician Assistant (PA) issued by the NYSED; and one (1) year of experience, as described in '1' above

Successful completion of education that leads to a clinical degree; and one (1) of experience, as described in '1' above

In addition to meeting the qualification requirements for Assignment Level I, appointment to Assignment Level II requires two (2) additional years of experience, including one (1) year of experience performing the essential duties and responsibilities of Assignment Level I

Successful completion of NYC Health + Hospitals' Supervisor Development Program within three (3) months of appointment or promotion