The Clinical Specialist II abstracts and enters clinical data in an accurate and timely manner from all available sources to provide the required data elements to various web-based venues. Learns and understands databases and terminology staying current on definitions/terminology changes, educating others as appropriate on process/terminology changes. Coordinates with the appropriate personnel to ensure all data elements are recorded, and performs validation for the components of the data collection process. Works to continually improve accuracy of data elements and prepares appropriate reports as required. Collects accurate data from optical imaging and the actual patient record, to provide valid and reliable patient information in accordance with the published standards. Qualifications Education/ Training. Associate’s degree in Nursing Licensure/ Certification FL RN License Experience - Five (5) years experience interpreting medical documentation relative to abstraction standards using defined algorithms and rule sets or three (3) years clinical experience. - Advanced computer skills including Outlook, Word, Excel and PowerPoint or similar office productivity software. - Knowledge of medical terminology Responsibilities Essential Functions - Reviews, abstracts, enters and analyzes clinical and administrative data for moderately complex abstraction tasks (Get with the Guidelines or similar) as assigned. - Collects accurate data from all available sources in accordance with current guidelines. - Maintains documentation and knowledge of current edition of guidelines for relevant data collection systems - Utilizes critical thinking, problem-solving and process improvement concepts to create an efficient work environment. - Communicates effectively with stakeholders regarding data quality, fallouts and current definitions/standards. - Analyzes aggregated data to identify opportunities for improvement, report outcomes and facilitate decision making by clinical improvement teams. - Uses basic statistical techniques for data analysis. - Assembles, analyzes & presents complex reports for regulatory agencies and internal quality improvement purposes according to department guidelines. - Maintains current knowledge of medical terminology sufficient to interpret the medical record for accurate abstraction. - Demonstrates responsibility for effective time management including ability to reprioritize as directed independently under general supervision with latitude for initiative and independent judgment. - Cross-trains to assist with multiple systems as necessary. - Trains new team members on a variety of systems to ensure compliance, data integrity, and prevent breaches of protected health information (PHI). - Functions as a resource to Orlando Health in the area of healthcare regulations, standards of care, and clinical performance improvement. - Works collaboratively with Clinical Practice Improvement personnel, HIM, various Clinical Nurse Specialists, Unit Based Educators, and Information Systems staff as appropriate. - Maintains working knowledge of quality improvement philosophy, methodologies, and applications as appropriate. - Maintains current knowledge of The Joint Commission standards related to Quality Improvement - Assists in documentation for and presents data to The Joint Commission and other accreditation/regulatory bodies as assigned. - Maintains clinical information accuracy rate in accordance with the published standards including quarterly testing for data integrity (must maintain accuracy of 95% or greater). - Informs direct leader of quality issues/concerns. - Demonstrates excellent communication skills with all team members - Provides feedback to leader regarding accuracy and usefulness of data collection systems as requested. - Assists in design and validation of dashboards as a subject matter expert - Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards. - Maintains compliance with all Orlando Health policies and procedures. Other Related Functions