Trauma Registrar
About The Position
The Trauma Registrar supports VCU Health System adult or pediatric Trauma Programs and organizational requirements for Level 1 Trauma Center verification by the Commonwealth of Virginia and the American College of Surgeons. The role maintains a trauma registry database by identifying cases for inclusion and abstracting data from sources such as the electronic medical record, prehospital databases, and other sources. The Trauma Registrar performs ongoing daily chart reviews, interprets medical information, assigns ICD-10 diagnosis and other specialized codes—including Abbreviated Injury Scale (AIS) scores—and enters data into the registry. The role reports complications and quality issues to the Supervisor, follows data management protocols to ensure accurate and timely reporting to the organization and regulatory agencies, and assists with performance improvement activities. The Registrar is assigned patients of basic to moderate complexity, including patients with multiple complications and deaths.
Requirements
- Proficiency with MS Office software, including email, MS Word, and MS Excel.
- An associate’s degree in any field that includes two semesters of medical terminology and Anatomy/Physiology, or a degree in medical records coding from an accredited program. Work experience may be considered in lieu of credentials not required by law, with HR approval, if the experience is specific to the role.
- Must obtain certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 24 months of hire.
- Must be willing and able to work evenings and weekends when necessary based on case volumes and state or national verification site surveys.
Nice To Haves
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), equivalent coding certification, or Registered Health Information Technician (RHIT).
- One or more years of experience in medical data abstracting or coding.
- Experience in trauma or surgery registry abstraction or coding, depending on job assignment.
- 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.
- Completion of ICD-10 coding courses.
Responsibilities
- Identify cases for inclusion in the trauma registry and abstract data from medical records, prehospital databases, and other sources.
- Perform daily chart reviews on assigned patients and enter data into the registry.
- Assign ICD-10 diagnosis codes and specialized codes, including AIS scores, to procedures, comorbidities, and complications according to applicable methodologies and coding rules.
- Interpret medical information.
- Report complications and quality issues to the Supervisor.
- Follow data management protocols to support accurate and timely reporting to the organization and regulatory agencies.
- Assist with performance improvement activities.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
