POSITION SUMMARY:
Perform high-quality medical record abstraction by combining proficient-level experiences in data management and software with medical terminology, medical coding, information encoding, and analytical capabilities. Interpret and manage complex clinical patient data for research, quality improvement, and regulatory reporting.
PRIMARY RESPONSIBILITIES:
Data Abstraction: Accurately review, interpret, and abstract clinical patient data from various electronic health record (EHR) systems, paper charts, and other source documents in accordance with defined project or research protocols, clinical, data, and technical specifications, and dictionaries.
Coding and Classification: Apply knowledge of medical coding systems (e.g., ICD-10, MedDRA, CPT, HCPCS) and standard of care guidelines, to interpret, classify and categorize abstracted clinical data points from unstructured text to standardized machine readable data in one common database schema.