Trauma Registrar - Southside Regional Medical Center
About The Position
The Trauma Registrar collects and abstracts database elements according to inclusion criteria for state and/or national trauma databases. Reporting directly to the Trauma Nurse Director/Manager, the role supports Southside Medical Center’s verification as a Level III Trauma Center by the Commonwealth of Virginia and compliance with American College of Surgeons standards for maintaining a trauma registry database. The registrar identifies cases for registry inclusion using sources such as the Master Patient Index, ED log, and Trauma Log, following National Trauma Data Bank standards. Data is abstracted from sources including the electronic medical record, prehospital databases, autopsy reports, and other electronic or non-electronic records. The role assigns ICD-10-CM diagnosis codes and ICD-PCS procedure codes according to published coding guidelines, as well as AIS codes for severity of illness and probability of survival using the AAAM manual. The registrar performs daily chart review and registry data entry for eligible patients, reports complications and quality issues to the Trauma PI Coordinator, ensures accurate and timely data management and reporting, and assists with performance improvement activities. Continued employment requires maintaining 95% data-validation accuracy after 12 months, completing onboarding training, and obtaining CAISS certification within 24 months of hire.
Requirements
- One year of work experience in registry data abstraction or coding.
- Two years of experience in medical data abstraction or coding.
- Proficiency with MS Office, including email, MS Word, and MS Excel.
- Completion of ICD-10 coding courses.
- Completion of college-level Anatomy/Physiology courses.
- Completion of college-level Medical Terminology courses.
- Work experience may be considered in lieu of credentials not required by law, with HR approval; qualifying experience must be specific to the role, such as emergency medical services or a healthcare-related field.
- Maintain data-validation scores of at least 95% accuracy following 12 months of employment and fulfill onboarding training requirements.
- Obtain CAISS certification within 24 months of hire.
Nice To Haves
- Preferred credentials: Certified Abbreviated Injury Scale Specialist (CAISS), Certified Specialist in Trauma Registries (CSTR), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Paramedic (EMT-P).
- Experience in trauma or surgery registry abstraction or coding.
- Expert skills using Windows-based word processing, spreadsheet, and database software.
- Abstracting experience using current state and national regulatory requirements.
- Experience with medical terminology and acronyms related to diagnoses, procedures, complications, and comorbid conditions.
- Experience with accurate and timely data entry and verification to maintain high data-quality standards.
- Associate’s degree in any field that includes two semesters of medical terminology and Anatomy/Physiology, or in medical records coding from an accredited program.
Responsibilities
- Identify cases for registry inclusion from the Master Patient Index, ED log, and Trauma Log using National Trauma Data Bank standards.
- Abstract data from electronic medical records, prehospital databases, autopsy reports, and other relevant sources.
- Assign ICD-10-CM diagnosis codes for diagnoses, comorbidities, and complications, and ICD-PCS procedure codes according to published Official Coding Guidelines.
- Assign and verify AIS codes for severity of illness and probability of survival using the AAAM manual.
- Perform daily chart review and enter data into the Trauma Registry for patients meeting established criteria.
- Report complications and quality issues to the Trauma PI Coordinator as soon as they are discovered.
- Follow data management protocols to ensure accurate and timely reporting to the organization and regulatory agencies.
- Assist with performance improvement activities.
Benefits
- Competitive pay, incentives, referral bonuses, and a 403(b) with employer contributions when eligible.
- Medical, dental, vision, and prescription coverage; HSA/FSA options; life insurance; mental health resources; and discounts.
- Paid time off, parental and FMLA leave, short- and long-term disability, and backup care for children and elders.
- Tuition assistance, professional development, and continuing education support.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
