Trauma Registrar

Cleveland Clinic

20h•Remote

About The Position

Under the direction and supervision of the Trauma Medical Director and Trauma Program Manager, the Trauma Registrar abstracts and codes medical record data on trauma patients according to guidelines established by the American College of Surgeons, Trauma Quality Improvement Program (TQIP), the State of Ohio Trauma Registry, and the regional trauma system. The Registrar performs all data collection, abstraction and entry of all trauma patients into the trauma registry and assigns ICD-9/ICD-10, ISS, AIS, E-Codes, and Trauma Scores. This role requires someone who can multitask in a fast-paced department. This is an excellent opportunity for someone who is looking to join a supportive team. The work culture in this department is positive, and communication is clear between all team members. You will be supported by leadership and professional development is encouraged. A caregiver in this position works remotely Monday - Friday 8:00 a.m. – 4:30 p.m. The preference is that candidates reside in the states of Ohio, Florida or Nevada.

Requirements

Knowledge of and skills using Epic and Excel
Complete 8 hours of trauma registry related continuing education per year as recommended by the American College of Surgeons
Obtain required certifications/education within one year of hire as directed by the American College of Surgeons (AAAM AIS, trauma registry and ICD 10 or updated versions)

Nice To Haves

Associate’s Degree in healthcare OR two years of experience including medical terminology
Certified Specialist in Trauma Registry (CSTR), Registered Information Technician (RHIT) or Certified Coding Specialist (CCS)
Previous data registry experience including knowledge in case abstraction, data entry, ICD-9 or ICD-10 coding, and AIS/ISS scoring
RHIT or coding background
Previous experience as a Trauma Registrar
Background in anatomy/physiology, and ASC site review

Responsibilities

Complete identification of patient records for entry into the trauma registry.
Collect, abstract and accurately enter trauma patient information into the trauma registry in a timely manner.
Complete final entry of patient data no later than 60 days post discharge.
Participate in data validation and maintain department standard.
Comply with all internal/external reporting requests and requirements.
Assist in the preparation for American College of Surgeons trauma center verification.
Ensure data is abstracted and submitted to meet the American College of Surgeons and State of Ohio data submission deadlines.
Close charts according to the American College of Surgeons guidelines.
Complete 8 hours of trauma registry related continuing education per year as recommended by the American College of Surgeons.
Obtain required certifications/education as directed by the American College of Surgeons (AAAM AIS, trauma registry and ICD 10 or updated versions).