Sr Clinical Data Abstractor

Clinical Background: U.

Strong understanding of medical terminology, disease processes (especially cancer), standard clinical workflows, and genetic testing.

Clinical Experience: Minimum of 4-5 years of experience in clinical data abstraction and medical records review, preferably in cancer, women’s health, rare diseases.

Data Abstraction Expertise: Proven ability to accurately read, interpret, and abstract complex clinical information from various electronic and paper medical record sources.

Data Management Expertise: Direct experience performing clinical data encoding using standard ontologies including but not limited to ICD-10-CM and SNOMED CT.

Direct experience performing data mapping, standardization, and harmonization.

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.

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.

Electronic Data Capture (EDC): Utilize specialized data management software (e.g., REDCap, registries, and custom built EDC systems) to enter, track, and maintain the integrity of clinical data encoded into queryable databases.

Technical Support: Aid cross-functional teams in translating clinical and data abstraction and encoding requirements.