JOB SUMMARY: Clinical Data Abstractor is responsible for completing the abstraction process to the assigned facility or institution. The clinical abstractor reviews the pertinent information in the medical record ensure completion and accuracy of reporting using the required system by the facility or institution. The clinical data abstractor must observe the confidentiality and privacy of patient health information. The clinical data abstractor must be able to meet minimum of 95% quality and productivity target set by the organization or by the client. SCOPE AND COMPLEXITY The work of this position is guided by defined policies guidelines and established practices and precedents. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Able to read locate and abstract specific information from medical records such as lab results cultures procedure notes clinical conditions. 2. Able to keep updated to the Centers for Disease Control and Prevention (CDC) s National Healthcare Safety Network (NHSN) guidelines and facilityspecific guidelines to ensure accuracy in the abstracting process. 3. Able to understand the terminology of microorganisms especially the Genus and Species. 4. Able to understand basic ICD10 PCS or CPT codes and modifiers for procedures. 5. Able to determine the infection window period (IWP) date of event (DOE) present on admission (POA) hospitalacquired infections (HAIs). 6. Able to ensure consistency and accuracy of data both in the logbook/worksheet and in the facility system. 7. Able to navigate different systems or applications such as Theradoc Meditech HPF. 8. Attends necessary education sessions to receive updated information and changes in abstractions and/or regulations. 9. Able to think independently and impartial judgment. 10. Able to adapt to technologies used in the clinical abstraction process. 11. Able to maintain the confidentiality of patient information. 12. Perform as a team player. 13. Able to adhere to all HIPAA privacy and security policies and practices. Reports violations and incidents they observe and cooperates in investigations as requested by management. 14. Capable of doing abstracting to its minimum as needed in the production. 15. Adhere to the individual MiraMed Philippines Code of Conduct Policy and Procedure memos as distributed. 16. Attendance in accordance with company HR and department policies 17. Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.
Clinical Data Abstractor
