CLINICAL DATA ABSTRACTOR

Operations RCM

Profile Overview

We are seeking a detail-oriented and analytical Clinical Data Abstractor to perform high-quality medical record abstraction. The role combines proficient-level experience in data management and software with strong knowledge of medical terminology, medical coding, information encoding and analytical capability. The incumbent will review, interpret and manage complex clinical patient data for research, quality improvement, registry, regulatory reporting and healthcare analytics initiatives.

Job Roles & Responsibilities

• Data Abstraction
• Review, interpret and abstract clinical patient data from electronic health record (EHR) systems, paper charts, medical charts, laboratory reports, physician notes and other source documents, in accordance with defined project or research protocols, clinical, data and technical specifications, and dictionaries.
• Accurately capture patient demographics, diagnoses, procedures, medications, laboratory results, outcomes and other required clinical variables.
• Apply standardized data abstraction guidelines and project-specific inclusion/exclusion criteria.

Coding and Classification

• Apply knowledge of medical coding systems (e.g., ICD-10, ICD-10-CM, SNOMED CT, MedDRA, CPT, HCPCS) and standard-of-care guidelines to interpret, classify and categorize clinical data points from unstructured text into standardized, machine-readable data within one common database schema.
• Perform data mapping, standardization and harmonization as required by the project.

Electronic Data Capture and Data Management

• Use specialized data management software (e.g., REDCap, registries, custom-built EDC systems and other clinical databases) to enter, track and maintain the integrity of clinical data in query able databases.
• Apply and support program-specific clinical data management best practices (CGDMP) and good clinical practice (GCP) so that data is accurate, legible, contemporaneous, original, attributable, complete and consistent across end-to-end ETL workflows.

Quality Assurance and Control

• Perform data validation and quality checks to identify missing, inconsistent or inaccurate information.
• Apply industry-standard best practices for the use of real-world data in research, quality monitoring and regulatory reporting, using technical and analytical software.
• Participate in training, audits and periodic quality-assurance activities.

Protocol Adherence and Compliance

• Maintain strict adherence to all project and research protocols, institutional review board (IRB) requirements, HIPAA and applicable data privacy regulations, data management best practices (e.g., DAMA, SCDM, ACRP and SOCRA) and organizational policies on patient privacy and data security.

Collaboration and Escalation

• Collaborate with clinical, research, data management and quality teams to resolve data discrepancies and clarify documentation.
• Identify and escalate ambiguous or incomplete clinical information appropriately.

Daily Operations and Reporting

• Provide timely and accurate daily, weekly or monthly abstraction submissions and productivity reporting.
• Meet established productivity, accuracy and turnaround-time requirements.
• Maintain documentation of abstraction decisions and follow standardized workflows.
• Actively participate in team meetings and workshops.
• Perform other duties and responsibilities as assigned.
• Candidate Requirements
• Education: BHMS, BUMS, BDS, BPT or an equivalent physician degree.
• Experience: Minimum of 1 year of experience in clinical data abstraction and medical records review, or in a closely related role such as clinical research or healthcare data management. Experience in cancer, women’s health or rare diseases is preferred.
• Clinical Knowledge: Strong knowledge of medical terminology, anatomy, physiology, common clinical conditions and disease processes (especially cancer), standard clinical workflows and genetic testing.
• Data Abstraction Expertise: Proven ability to accurately read, interpret and abstract complex clinical information from electronic and paper medical record sources, and to navigate EMRs and clinical documentation.
• Data Management Expertise: Direct experience performing clinical data encoding using standard ontologies, including but not limited to ICD-10-CM and SNOMED CT, along with data mapping, standardization and harmonization.
• Quality and Compliance: Demonstrated commitment to data integrity, quality control processes, and adherence to HIPAA and other data privacy regulations.
• Technical Proficiency: Proficiency with Microsoft Office (particularly Excel) or Google Suite, including creating pivot tables, generating reports and performing data analysis; working knowledge of clinical data systems and databases such as fillable forms, EDCs and data registries.
• Communication: Excellent written and verbal communication skills, with the ability to collaborate effectively with clinical and non-clinical teams.
• Autonomy: Proven ability to work independently, manage time, prioritize and organize tasks, and meet strict productivity and quality deadlines.
• Certifications: Maintenance of all relevant clinical or technical licensures and certifications, where applicable.
• General Expertise
• High level of initiative and self-motivation.
• Able to work as part of a team on high-visibility projects with high rates of communication.
• In-depth attention to detail and a fast learner.
• Responsive to shifting priorities and changes.
• KEY COMPETENCIES
• Clinical knowledge and medical terminology
• Data quality management
• Medical coding and data encoding
• Data abstraction and validation
• Attention to detail
• Analytical and critical-thinking skills
• Time management and prioritization
• Confidentiality and compliance
• Communication and teamwork
• Initiative, self-motivation and adaptability to shifting priorities PERFORMANCE EXPECTATIONS
• Maintain high levels of abstraction accuracy and consistency.
• Complete assigned records within established turnaround times and meet productivity and quality deadlines.
• Identify and escalate ambiguous or incomplete clinical information appropriately.
• Consistently follow project-specific abstraction guidelines, protocols and quality standards.
• Safeguard patient confidentiality and always comply with HIPAA and data security requirements.
• Kindly Note: At Credence, we uphold the highest standards of integrity in our recruitment process. We do not charge any fees at any stage of the hiring process, and we strictly prohibit any third parties, vendors, or individuals from soliciting money in exchange for job opportunities at Credence.
• If you are approached by anyone requesting payment or offering you a position at Credence in exchange for money, do not engage with them. Such actions are fraudulent and not authorized by Credence. Please report any such incidents immediately to our official HR team at hr@credencerm.com
• Your safety and trust are important to us. Thank you for helping us maintain a fair and transparent hiring environment.