Trauma Registrar

Bon Secours Mercy Health • Petersburg, VA

1d • 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. The Trauma Registrar, reporting directly to the Trauma Nurse Director/Manager, 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 Trauma Registrar 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. Data abstracted will be 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. The Trauma Registrar will assign 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. The Trauma Registrar will assign and verify AIS codes required for severity of illness and probability of survival as established through AAAM manual for AIS coding. Daily chart review and data entry into the Trauma Registry on established patients who meet criteria will be performed. The Trauma Registrar reports all complications and quality issues to the Trauma PI Coordinator as soon as discovered. The Trauma Registrar ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies. The Trauma Registrar assists with performance improvement activities.

Requirements

• Proof of ICD-10 coding coursework.
• Proof of college-level Anatomy/Physiology coursework.
• Proof of college-level Medical Terminology coursework.
• 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.

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.

Responsibilities

• Collection and abstraction of data base elements following the criteria of inclusion for state and/or national trauma databases.
• Supports organizational requirements for verification as a Level III Trauma Center.
• Identifies cases for inclusion into the registry data base from various sources.
• Abstracts data from various sources including electronic medical records, prehospital databases, autopsy reports, and other data sources.
• Assigns ICD-10 CM diagnosis codes for diagnosis, comorbidities and complications.
• Assigns ICD-PCS procedure codes for procedures.
• Assigns and verifies AIS codes required for severity of illness and probability of survival.
• Performs daily chart review and data entry into the Trauma Registry.
• Reports all complications and quality issues to the Trauma PI Coordinator.
• Ensures adherence to data management protocols for accurate and timely reporting.
• Assists with performance improvement activities.

Benefits

• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
• Medical, dental, vision, prescription coverage, HSA/FSA options, life insurances, mental health resources and discounts
• Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders
• Tuition assistance, professional development and continuing education support

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed