Job Summary The candidate will be responsible for reviewing medical records and abstracting accurate clinical data related to core measures, trauma, VON and/or cardiovascular services. The role involves ensuring compliance with applicable CMS, The Joint Commission (TJC), NHSN and other regulatory or accreditation standards.
Key Responsibilities
- Review patient medical records and abstract relevant clinical data into designated systems.
- Ensure the accuracy, completeness and timeliness of clinical data abstraction.
- Perform case follow-ups, edit checks and validation of abstracted records.
- Identify and correct rejected records and resolve data discrepancies.
- Follow applicable CMS, TJC, NHSN and internal abstraction guidelines.
- Prepare and submit reports within established timelines.
- Maintain updated knowledge of clinical abstraction standards and regulatory requirements.
- Coordinate with facility managers and relevant teams to resolve documentation issues.
- Maintain confidentiality and accuracy while handling patient information.
Required Qualifications
- Bachelor's degree.
- Successful completion of a certified medical coding program.
- Solid analytical, problem-solving and communication skills.
- Ability to review medical documentation and extract accurate clinical information.
- Knowledge of medical terminology, anatomy, coding logic and patient discharge disposition.
- Proficiency in Microsoft Office, especially Excel.
Preferred Qualifications
- One year of experience in Health Information Management (HIM) or US healthcare.
- Experience in medical coding or health registry abstraction.
- Trauma and Emergency Room (ER) coding or abstraction experience preferred.
- Experience in a healthcare, GCC/shared-services or regulated environment.
- Knowledge of Lean/Six Sigma or process improvement is an advantage.
Excel Skills
- Experience handling large datasets.
- Knowledge of PivotTables, lookup functions and structured trackers.
- Ability to validate data and prepare reports accurately.