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, deemed 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.

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 etc.) 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, escalate 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 fall out trend insights, and support abstraction enhancing workflows.

Education

· 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