Trauma Registrar

BMC Software

3d•$24 - $34

About The Position

The Trauma Registrar identifies, abstracts, and maintains comprehensive records for trauma patients in the trauma registry data system. The role ensures the accuracy, integrity, and timeliness of data by collecting, entering, validating, and reporting information for every trauma patient treated at Boston Medical Center. This work supports the institution’s qualification and continued compliance as a Level I Trauma Center. The registrar conducts data analysis and disseminates information according to ethical, legal, and confidentiality standards, and maintains required education, competencies, and professional certifications in alignment with American College of Surgeons standards. The position is in the Critical Care & Trauma Surgery department and is full-time. Complete and validated data entry for all trauma patients is expected within two months of hospital discharge.

Requirements

Associate degree or equivalent combination of formal education and experience.
One year of ICD-10 coding and data-entry experience.
AAAM Abbreviated Injury Scale (AIS) certification, trauma registry course completion, and ICD-10 course completion; if not already certified, successfully complete these within six months of hire. Refresher courses are mandatory.
Demonstrated ICD-10 coding skills.
Advanced medical terminology knowledge.
Demonstrated computer skills.
Effective communication skills.

Nice To Haves

Associate degree in a health-related discipline.
Two to three years of experience in trauma registry operations, clinical data abstraction, health information management, or a related hospital-based data role.
Demonstrated experience with AIS coding, ISS calculation, and ICD-10 diagnostic and procedural coding in accordance with ACS standards.
Prior work in an ACS-verified trauma center or a high-volume emergency or critical-care environment.
Experience with trauma registry software such as Collector, TraumaBase, V5, or equivalent, and with electronic health record systems.
Ability to analyze clinical data, generate reports, support research activities, and meet state and national trauma data submission requirements.
Familiarity with performance improvement processes, quality assurance, and regulatory reporting in a healthcare setting.
Knowledge of a trauma registry system.

Responsibilities

Perform concurrent abstraction and data entry for injury-related hospital admissions, deaths, transfers, and all Full and Modified Trauma Team activations.
Accurately capture all data elements from the time of injury through rehabilitation in the trauma registry.
Ensure ICD-10 diagnostic codes, Abbreviated Injury Scale (AIS) codes, and Injury Severity Scores (ISS) accurately reflect documented injuries and severity.
Identify and validate new trauma cases that meet registry inclusion criteria.
Collaborate with physicians, nurses, ancillary staff, and the multidisciplinary trauma team to support trauma-program goals, standards, and performance improvement initiatives.
Communicate with the Trauma Program Manager regarding patient-care documentation, data collection, reporting needs, and registry operations.
Report significant gaps, inconsistencies, or deficiencies in medical-record documentation to the Trauma Program Manager.
Manage workload to complete and validate data entry for all trauma patients within two months of hospital discharge.
Perform additional related duties supporting trauma-program operations, quality improvement, and regulatory compliance.