Clinical Abstractor VA

A clinical abstractor who reads medical records and extracts accurate, coded data for registries, HEDIS measures, quality reporting and research. Your quality scores, registry submissions and audits rest on data that has been checked line by line.

Description

A Clinical Abstractor VA reviews medical records and extracts coded clinical data for registries, HEDIS measures, quality reporting and research projects. They can locate supporting evidence, identify care gaps and maintain consistent abstraction standards across large volumes of charts. Outsource Teams provides top 1% vetted talent with clinical abstraction or health information experience, no lock-in contracts and a replacement guarantee.

Responsibilities

  • Review medical records and abstract required data elements into registry, HEDIS or quality-measure tools according to the measure specifications.
  • Apply the current measure definitions, for example NCQA HEDIS technical specifications, CMS quality measures or registry data dictionaries, precisely and consistently.
  • Locate supporting evidence in the chart for each abstracted element and record the source page and date.
  • Identify gaps in care and non-compliant records and flag them for the quality team's outreach.
  • Maintain inter-rater reliability of 95 percent or higher through regular over-reads and calibration sessions.
  • Meet productivity targets for charts abstracted per day without sacrificing accuracy.
  • Query clinical staff for clarification when documentation is contradictory or incomplete.
  • Track and report abstraction progress, exclusion rates and data quality issues to the project lead.
  • Protect patient information under HIPAA and the client's data handling rules.

Software & Tools

Epic Cerner REDCap Microsoft Excel ICD-10-CM

Requirements

  • At least 5 years of clinical abstraction, HEDIS, registry (for example NCDR, NSQIP, GWTG or cancer registry) or clinical documentation improvement experience.
  • Nursing, allied health or health information degree; RN, CTR, RHIT or CCDS credentials are preferred.
  • Strong clinical knowledge to interpret progress notes, lab results, medications and procedures across specialties.
  • Experienced with EHRs such as Epic, Cerner or Meditech and with abstraction platforms or registry software.
  • Meticulous attention to detail with a documented accuracy record on over-read audits.
  • Clear written English for queries and data notes and spoken English for calibration calls.
  • HIPAA training completed.
  • Reliable high-speed internet and backup power, with availability overlapping the client's business hours for team calibration.

Frequently Asked Questions

What data can they abstract?

They can extract required clinical data elements from medical records according to registry, HEDIS and other quality-measure specifications.

Can they identify gaps in care?

Yes. They can flag missing or non-compliant records for follow-up by the quality team.

What systems can they use?

They can work with Epic, Cerner, REDCap, Microsoft Excel and ICD-10-CM.

How experienced are the candidates?

Candidates are expected to have at least five years in clinical abstraction, HEDIS, registry work or clinical documentation improvement.

How much does it cost?

Rates are listed in USD at $9 per hour for entry-level talent, $12 per hour for intermediate and $15 per hour for senior talent. Both full-time and part-time options are available.

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