Quality Coordinator - Core Measures Abstractor

Location: Scenic Mountain Medical Center

Posted Date: 5/10/2021

About SMMC:

Scenic Mountain Medical Center is a community health care provider serving patients in Howard County. An acute care hospital with 95 licensed beds, Scenic Mountain is Joint Commission accredited. Our specialized services include cardiology, orthopedics, maternity, diagnostic imaging, emergency care with a 24/7 level IV Trauma Center, wound care, and women's health and breast care services.

About the Shift:

Monday Friday; 8a-5p

About the Position:

The Quality Coordinator is responsible for abstracting quality data from the medical record for the Core Measure Data Sets. The Quality Coordinator will participate on quality improvement teams/committees and facilitate the team/committee activities. The Quality Coordinator will assist the Chief Quality Officer (CQO) with DNV preparation. The position reports directly to the Chief Quality Officer.

• Attends SHCS on-line training required for data collection.
• Receives selected identified medical record list from Quality Abstraction System based on sample size of records to be abstracted on a monthly basis
• Performs 100% review of medical records form timely abstraction
• Performs 100% review of records based on SHCS monthly audit list
• Validates that diagnosis supports record to be included in abstraction process and appropriate patient population
• Abstracts/audits and enters quality data from the medical record retrospectively for Core Measure Data Sets: AMI, IMM, ED, Stroke, Sepsis, Perinatal and BHU measures
• Ensures medical record is complete for abstraction process. Gathers all un-filed reports and dictation prior to abstracting record. Only uses reports and dictation completed in the normal course of chart completion.
• Communicates with physician offices, nursing homes, home health, and clinics as appropriate to obtain additional information that may be needed to complete the abstract and avoid a "negative" response
• Performs concurrent review for the required Core Measure elements
• Responsible for maintaining a current abstraction manual
• Correlates and analyzes data; assists with preparation of data for presentation to departments, committee
• Assists with activities of quality improvement teams and committees.
• Prepares minutes of meetings, accurately recording information discussed, action items and necessary follow-up.
• Participates in the orientation of new staff members including but not limited to quality outcomes, documentation, and regulations.
• Completes work and documentation with accuracy and within organizational time frames.
• Assists Medical Staff in conducting an effective Core Measure program
• Transmits completed abstracts electronically when all data has been completed
• Reports deficiencies weekly to the Chief Quality Officer.
• Maintain abstraction accuracy by an annual CDAC validation score > 80%.
• Reviews all charts requested by CDAC for validation prior to submission to assure the correct chart, entire chart, and legible chart is sent.
• Address patient complaints and grievances by working with department leaders
• Timeliness of Letters in response to the patient/family complaints and grievances meet the CMS standards.
• Creates a collaborative, productive work environment through positive relationships with Senior Leadership, Managers, employees, patients/families and the community.
• Listens to customer without interruption.
• Takes actions to appropriately and successfully address customer issues; effectively communicates with customers.
• Demonstrates respect for diverse cultures of all patients, families and co-workers.
• Honors the SHCS Customer Service Standards and Cares Philosophy.

Regulatory Requirements:

Education: Current Registered Professional Nursing license required. Associates degree required.

Licenses/Certificates: Current license as Registered Professional Nurse
Advance certificate and training preferred.

Experience:
Core Measures Abstraction experience preferred. Previous acute care clinical experience required. Attention to detail and follow-up necessary. Strong interpersonal skills and the ability to communicate with patients, families, hospital staff, physicians and community resources are required.

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.