Overview
The Clinical Quality Data Abstractor is responsible for the accurate, timely, and complete abstraction of complex clinical quality measures from the electronic health record and other data sources. This role supports regulatory reporting to CMS, designated status accrediting organizations (TJC, DNV), and state‑directed payment programs such as KY HRIP and WV DPP, ensuring data integrity and compliance with all data abstraction specifications.
Special Instructions
Can be remote, work from home position with appropriate private home office set up.
Responsibilities
High Complexity Clinical Data Abstraction: Use EHR, data abstraction platform and abstraction specifications manuals from various entities (e.g., CMS, DNV, TJC, State DPP Programs) to accurately abstract data for measures of varying degrees of complexity, including highly complex measures.
Documentation Validation Across Multiple Systems: Utilize documentation from multiple systems (e.g., Meditech, scanned records, ED logs) to ensure completeness and accuracy of abstracted date elements.
Apply Measure Logic: Use abstraction manual, abstraction platform resources, quality program data dictionaries and encyclopedias of measures to apply measure logic and inclusion/exclusion criteria with precision, escalating ambiguous cases for second‑level review.
IRR Participation: Participate in inter‑rater‑reliability (IRR) audits and maintain a ≥95% agreement rate.
Training & Development: Maintain up‑to‑date knowledge of abstraction specifications and regulatory changes through continuing education; support onboarding and peer mentoring of new abstractors as needed.
Stakeholder Engagement: Collaborate with clinical teams to clarify documentation, provide fallout trend insights, and support abstraction‑enhancing workflows.
Qualifications
Associate’s degree in clinical field or HIM required.
Clinical licensure (RN, PharmD, RT, PT, LCSW, etc.) required unless HIM professional certification.
Minimum Work Experience
Minimum 1 year in bedside nursing or front‑line clinical role in a hospital setting required.
Minimum 2 years complex clinical data abstraction (e.g., Sepsis, PC measures, Stroke).
Familiarity with CMS data specifications, IRR audits and abstraction platforms.
Demonstrated participation in IRR audits with ≥95% agreement (internal candidates only).
Licensures and Certifications
Licensure in a clinical field required. Certified Professional in Healthcare Quality – preferred. Certified Health Data Analyst – preferred.
Required Skills, Knowledge, And Abilities
Demonstrated proficiency in abstracting CMS and regulatory core measures including Sep‑1, PC Measures, OP‑18 and OP‑23.
Strong understanding of clinical workflows, medical terminology and documentation standards.
Ability to interpret complex clinical situations and apply abstraction logic and specifications accurately.
Experience with electronic health records (EHR) systems, preferably Meditech, abstraction platforms and secure remote access tools.
High attention to detail and commitment to data integrity over speed.
Strong written and verbal communication skills, able to document rationale for abstraction decisions.
Seniority level
Entry level
Employment type
Full‑time
Job function
Design, Art/Creative, and Information Technology
Industries
Hospitals and Health Care
Location and Compensation
Lexington, KY
$57,000.00-$62,500.00