Job Summary

Coordinates all aspects of targeted clinical indicators form abstraction, analysis of documentation, format and dissemination of knowledge. Translates clinical documentation into data elements for the purpose of driving quality improvement knowledge in all areas of clinical quality. Identifies deficiencies in documentation based on clinical profile of patients, communicates deficiencies to medical staff, assures integrity of database for key clinical indicators, can do basic analysis of data using basic statistical tools and report writers to create knowledge base. Coordinates the functions of this specific knowledge management.

Responsibilities

• Able to see the clinical picture of the patient using all sources of data and then identifying documentation deficiencies based on completeness of the clinical picture. Validate questions about specific clinical information with physicians or designee.
• Responsible for the accurate input of data from the medical record. Demonstrate the ability to assimilate and extract clinical data using clinical knowledge and analytical thinking. Assists with development and implementation of valid tools and methods for collection of data.
• Participate in preparing summaries and reports. Assist those involved in studies, research, quality projects, etc. Edit data utilizing appropriate software. Directs the information to the right source so that management of the knowledge generated can occur.
• Recognize the deficiencies in data and take steps to validate both manually abstracted and electronically captured quality measures and in assist with the development of standards for data output to endure high degree of accuracy.
• See reliable sources and maintain currency and availability of knowledge related to abstraction guidelines as defined by CMS, comparative databases, specialty medical organization standards and guidelines for benchmarking.
• Participate in evaluation of effectiveness of clinical quality programs by maintaining and providing overview and summary documents and comparisons of studies and results.
• All other duties as assigned.
• Assist with the education of identified subject matter experts as well as others related to abstraction guidelines as defined by CMS.
• Advocate for Cerner documentation to reflect CMS standards for manually abstracted measures.
• Maintain department, institution, and licensure (if applicable) required education. Document appropriately.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities
(Essential duties common to all positions)

1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.

Education 

• Associate's Degree (Required) Experience: 2 Years Clinical Nursing Experience

Credentials 

• Registered Nurse (Required)

Work Schedule: Days

Status:  Full Time Regular 1.0

Location: Teays Valley Hospital

Location of Job: US:WV:Hurricane

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org