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.