The System Manager for Clinical Quality Data Abstraction is responsible for leading the centralized abstraction team that

performs accurate, timely, and complete abstraction of complex clinical quality measures from the electronic health

record and other data sources. Central abstraction supports regulatory reporting to CMS, deemed status Accrediting

Organizations (TJC, DNV), and state-directed payment programs such as KY HRIP and WV DPP. This role ensures

abstraction integrity, regulatory compliance, and continuous performance improvement across the system.

· Oversee High Complexity Clinical Data Abstraction: Oversee team of

individuals performing abstraction including onboarding, staffing, assignment,

training, productivity monitoring and quality assurance. Ensures abstraction staff

utilize 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. Monitor abstraction timelines and ensure timely data submission.

· Develop and Maintain Effective Abstraction Workflows: Establish and maintain departmental standard operation procedures, policies, workflows and audit protocols that align with CMS, KY HRIP, WV DPP and other regulatory and/or value-based programs.

· Serve as Liaison to Critical Stakeholders: Serve as liaison to Quality, Compliance, IT, Medical Staff and Clinical Operations to resolve documentation and data source/data access issues. Analyze abstraction data trends for gaps and improvement opportunities, present findings and work with various stakeholder groups on performance improvement.

· Lead Industry Standard Inter-rater Reliability (IRR): Lead IRR audits and second level review protocols and implement corrective action plans to maintain ≥95% abstraction accuracy.

· Training & Development: Maintain team competency through continuing education, regular specifications updates, strong IRR and second level review program and ongoing coaching.

Education

· Bachelor’s degree in clinical field or HIM required · Clinical licensure (RN, PharmD, RT, PT, LCSW etc.) required

Minimum Work Experience

· Minimum 1 year in a clinical leadership role in a hospital setting required · Minimum 2 years complex clinical data abstraction (e.g., Sepsis, PC measures, Stroke) · Additional years of clinical leadership experience can be substituted for complex data abstraction experience, with no fewer than 6 months of complex clinical data abstraction required · 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

· Proven leadership in clinical data abstraction, quality reporting, or health information management

· Deep knowledge of CMS and regulatory core measures including Sep-1, PC Measures, OP-18 and OP-23 abstraction specifications

· Strong understanding of clinical workflows, medical terminology and documentation standards

· Ability to interpret complex clinical situations and apply abstraction logic and specifications accurately

· Proficiency with abstraction platforms, EHRs and regulatory reporting portals

· High attention to detail and commitment to data integrity over speed

· Skilled in IRR methodology, audit design, and abstraction performance analytics

· Strong organizational and communication skills, able to translate technical requirements into actionable workflows