Registered Nurse, Trauma Registrar

Mercy Health System Corporation•Janesville, WI

3d•Onsite

About The Position

Support the trauma program by reviewing medical records, collecting and entering trauma patient data, and maintaining accurate information for state and national trauma registries. This role works closely with clinical teams and trauma program staff to ensure compliance with reporting requirements, improve data quality, and support trauma care and performance improvement initiatives.

Requirements

General knowledge of medical-record keeping principles and practices.
General knowledge of ICD-10 medical coding system.
Skill in the use of medical dictionaries, textbooks, and the ICD-10 coding manual as references.
Skill in communicating orally with a variety of people to obtain, clarify, or exchange information.
Ability to analyze medical records to determine inaccurate or insufficient information such as forms, reports, notes, or physician's signature in compliance with medical record keeping.
Ability to perform quality abstracting and coding of medical records under specific workload turnaround times in compliance with federal and state laws, American College of Surgeons, National Trauma Data Bank, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines, and hospital policies.
Ability to maintain confidentiality of medical information reviewed in medical records.
Ability to work with frequent interruptions.
ED or EMT background - familiar with traumatic injuries.
Graduate of an accredited nursing program.
ADN required upon hire, BSN preferred.
Licensed as an RN in state of practice
BLS certification
Basic knowledge of keyboard skills and medical terminology preferred.
Excellent oral communication skills and organizational skills
Ability to handle stress and problem solve
Computer experience preferred
Able to work independently
May include color blind test per department guidelines

Nice To Haves

Two years of ER experience preferred
Two years of chart auditing or data extraction preferred

Responsibilities

Learn and apply the Abbreviated Injury Scoring System.
Identify medical records for trauma registry entry.
Read and review medical records of trauma patients after discharge.
Work with EMR to obtain records and most up-to-date data requirements for Level II Trauma Centers.
Enter information into the Trauma Registry computer system as required.
Run reports for the Trauma Service on specific system and patient data.
Upload trauma records to the state of WI, NTDB and TQIP on a quarterly basis.
Attend Trauma Registry meetings.
Be available as contact person for Image Trend Vendor Digital Innovations.