Trauma Registrar - Medical Coding - Southside Medical Center

Bon Secours Mercy Health•Petersburg, VA

13d•$22 - $33•Onsite

About The Position

The Trauma Registrar is responsible for the collection and abstraction of data base elements following the criteria of inclusion for state and/or national trauma databases. This role supports the Southside Medical Center’s organizational requirements for verification as a Level III Trauma Center by the Commonwealth of Virginia and the standards set forth by the American College of Surgeons for maintaining a trauma registry database. The Registrar identifies cases for inclusion into the registry database from various sources, abstracts data from multiple sources including electronic medical records, prehospital databases, and autopsy reports. They will assign ICD-10 CM diagnosis codes, ICD-PCS procedure codes, and AIS codes for severity of illness and probability of survival. Daily chart review and data entry into the Trauma Registry will be performed. The Registrar reports all complications and quality issues to the Trauma PI Coordinator and ensures adherence to data management protocols for accurate and timely reporting. The role also assists with performance improvement activities.

Requirements

One (1) year work experience in registry data abstraction/coding
Two (2) years experience in medical data abstraction/coding.
Proficiency with MS Office software 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
Ongoing data validation scores at the level of 95% accuracy following 12 months of employment and fulfillment of onboarding training requirements.
Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 24 months of hire is required for Trauma Registrars.

Nice To Haves

Experience in trauma or surgery registry abstraction/coding
Expert skills using Windows-based software (word processing, spreadsheet, databases)
Abstracting experience using current requirements by state and national regulatory bodies.
Experience with medical terminology and acronyms related to diagnosis, procedures, complications and comorbid conditions
Experience with accurate and timely data entry and verification to maintain high standards of data quality control
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.
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)
Paramedic (EMT-P)

Responsibilities

Collection and abstraction of data base elements following the criteria of inclusion for state and/or national trauma databases.
Supports the Southside Medical Center’s organizational requirements for verification as a Level III Trauma Center by the Commonwealth of Virginia and the standards set forth by the American College of Surgeons for maintaining a trauma registry database.
Identifies cases for inclusion into the registry data base from various sources including the Master Patient Index, the ED log, and the Trauma Log based upon the guidelines of National Trauma Data Base standard.
Abstracts data from various sources including, but not limited, to the electronic medical record, prehospital databases, autopsies reports, and other data sources, either electronic or not that will substantiate the injured patient.
Assigns ICD-10 CM diagnosis codes for diagnosis, comorbidities and complications and ICD-PCS procedure codes for procedures according to the established and published Official Coding Guidelines.
Assigns and verifies AIS codes required for severity of illness and probability of survival as established through AAAM manual for AIS coding.
Performs daily chart review and data entry into the Trauma Registry on established patients who meet criteria.
Reports all complications and quality issues to the Trauma PI Coordinator as soon as discovered.
Ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies.
Assists with performance improvement activities.