The Clinical Reviewer is responsible for collecting, analyzing and reporting clinical data elements on eligible cases for CMS, TJC, and multi-hospital collaborations to improve Quality & Safety (CQI). The Clinical Reviewer will be required to independently manage the caseload and report data according to established standards and deadlines. The Clinical Reviewer may participate in activities to improve compliance to the measures by working with physicians, nurses, other clinicians, and administrators to understand the defects, to improve documentation, and to understand the measure requirements.
Functions and Responsibilities
- Maintain current knowledge of clinical indicators and compliance requirements.
- Provide concurrent and/or retrospective medical record review to assess documentation compliance and facilitate recommended interventions through alerts/communication with appropriate clinical staff.
- Manage tools to collect outcome data and providing regular feedback to individuals, managers, and leaders.
- Identifying staff learning needs related to clinical measures and provide/refer for education and training.
- Identify and abstract medical records per client specifications. Clinical populations include but are not limited to Heart Failure, Acute MI, Pneumonia, Surgical Care Improvement Project (SCIP) and Stroke.
- Provide consultation and support to clinical/operational teams.
- Remain current on measure specifications.
- Review medical record thoroughly, have complete understanding of the documentation.
- Participate in the validation of measures and IRR; must pass validation as required by client.
- Transmit data elements to clients database according to established standards and guidelines.
- Review QNet questions and answers on a regular basis.
- When specifications do not provide clear direction, submit clarifying questions to QNet.
- Identify opportunities for improvement (OFIs) when measures are not met.
- Identify reason for defect if possible.
- Prepare analysis report summarizing Opportunities for Improvement.
- Identify and recommend documentation improvements.
- Provide timely responses to questions or concerns communicated by clinical champions, nursing leaders, executive management team, and corporate office staff.
- Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution.
- Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to St. Joseph Mercy Health System. Discusses patient and hospital information only among appropriate personnel in appropriately private places.
- Behaves in accordance with the Mission, Vision and Values of SJMHS.
- Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
Other functions and Responsibilities
- Performs other duties as assigned.
Required Education, Experience and Certification/Licensure
- Education: Associates degree required. RHIT, Medical Assistant, LPN or RN licensure preferred.
- Experience: 3 years of experience in medical records and/or abstraction required. Thorough knowledge of healthcare systems with hospital experience.
Required Skills and Abilities
- Proficient in Microsoft Office Products, industry related core measure abstraction software systems and electronic medical record applications.
- Ability to analyze, interpret and display data.
- Excellent communication and documentation skills.
- Strong attention to detail.
- Ability to work independently.