GENERAL SUMMARY:

Under minimal supervision, performs chart abstraction, data entry, interrater reliability studies and abstraction review for JCAHO Core Measures/Centers for Medicare and Medicaid Services (CMS) Hospital Quality Alliance Measures and other initiatives that will ultimately result in publicly reported data that will have a direct impact on hospital reimbursement. Supports compliance with regulatory bodies (including but not limited to CMS, JCAHO, and IDPH) through data collection, data analysis and communication of necessary information to leadership within the organization. Supports Performance Improvement (PI), Risk Management and Medical Care Evaluation activities through audit design, data collection/analysis and committee participation. Participates in PI initiatives, Medical Care Evaluation (MCE) and Risk Management projects as needed for data collection or other activities.

CORPORATE PHILOSOPHY:

It is the obligation of each employee of Edward - Elmhurst Health to abide by and promote the mission and values of the System to ensure that excellent services are delivered with compassion.

PRINCIPAL DUTIES AND RESPONSIBILITIES: (The following duties and responsibilities are all essential job functions, as defined by the ADA, except those that begin with the word "May.")

• Supports the JCAHO Core Measures/CMS Hospital Quality Alliance Measures and other public reported data initiatives. Performs chart abstraction. Enters data into designated database within specified timeframes accurately. Performs interrater reliability studies as dictated by the program. Participates in data review groups prior to submission of data. Identifies issues and concerns regarding clinical documentation and practices reflected therein. Provides feedback/recommendations as needed for improved efficiency and accuracy of data collection and clinical documentation practices.
• Supports data needs in regards to regulatory compliance (i.e. JCAHO, CMS, IDPH), hospital performance improvement (PI) initiatives, risk management activities and Medical Care Evaluation committees. Designs data collection tools and processes, and delegates duties to co-workers as needed. Independently performs chart abstraction or other data collection appropriate to the project. Aggregates data into formats that facilitate interpretation and analysis. Communicates data as needed through the organization.
• Organizes and compiles quality data into a variety of presentation formats to meet the needs of teams and projects. Coordinates with end users with respect to their desired final results. Makes recommendations to end users regarding selection of format to optimize analysis.
• Participates in PI initiatives/committees, Risk Management, MCE and other projects as needed for data collection, membership, or other activities.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

Education, Experience and/or Skills Required:

• Associate’s Degree in healthcare related field
• Significant clinical experience and/or knowledge of medical terminology

Education, Experience and/or Skills Preferred:

• A minimum of two years of quality/data analyst experience
• Basic skills with Excel, Word and PowerPoint required; advanced skills
• Previous experience with database software

License/Certification Preferred:

• Current state of Illinois Registered Nurse, Licensed Practical Nurse, Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) certification or registration with American Society of Clinical Pathology (ASCP) or equivalent