Job DescriptionJob Summary:
Responsible for the collection, abstraction, validation, and submission of clinical data to support CMS quality programs, patient safety measures, national clinical registries and/or peer review data. Ensures the accuracy and integrity of reported data, supports compliance with regulatory requirements, and contributes to performance improvement initiatives. Applies clinical knowledge to identify trends, monitor quality outcomes, and provide actionable feedback to leaders and clinicians. Supports confidentiality of peer review activities, prepares trended reports for leadership and medical staff committees, and assists in maintaining compliance with accreditation and regulatory standard. Is essential to achieving internal and external quality and patient safety targets.
Job Requirements:
Education and Work Experience:
- Associate's or Technical Degree in Nursing, Healthcare Administration, or Health Information Management or equivalent combination of education and experience: Required
- Two years' of experience in quality management, data abstraction, or healthcare analytics: Required
- Three years' of experience in peer review, abstraction, quality assurance, or hospital data reporting: Preferred
Licenses/Certifications:
- Registered Nurse (RN) license or equivalent health background: Preferred
- Certified Professional in Healthcare Quality (CPHQ) or CPPS: Required
Essential Functions:
- Performs concurrent and retrospective chart abstraction for peer review, quality, and regulatory reporting using defined criteria. Ensures data accuracy and timeliness of submissions to internal and external databases.
- Performs case abstraction for assigned registries and/ or CMS IOR and QOR measures (e.g., STS, CoC, NSQIP, or other specialty registries). Collaborates with outsourced registry vendors and maintain effective communication with system quality teams. Ensures timely data submission to meet internal and external reporting requirements.
- Serves as a liaison between the Quality Department, clinical stakeholders, and registry partners. Provides feedback to physicians, nurses, and leaders on documentation gaps or trends impacting data accuracy. Supports initiatives to improve compliance with quality metrics.
- Adheres to all confidentiality requirements under state and federal peer review protections. Ensures that data collection and storage comply with Evidence Code a71157, PSWP, and organizational policies.
- Monitors data trends to identify opportunities for clinical process improvement. Provides reports and data insights to Quality and Patient Safety leaders. Supports performance improvement teams with accurate, validated data to guide interventions.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
