Trauma Registrar - Southside Regional Medical Center

Bon Secours Mercy Health • Petersburg, VA

5d

About The Position

The Trauma Registrar collects and abstracts database elements for inclusion in state and/or national trauma databases. Reporting directly to the Trauma Nurse Director/Manager, the registrar supports Southside Medical Center’s requirements for Level III Trauma Center verification by the Commonwealth of Virginia and compliance with American College of Surgeons standards for maintaining a trauma registry database.

The registrar identifies eligible cases using sources such as the Master Patient Index, emergency department log, and trauma log, applying National Trauma Data Bank standards. Data is abstracted from sources including the electronic medical record, prehospital databases, autopsy reports, and other electronic or non-electronic records that substantiate the injured patient. The registrar assigns ICD-10-CM diagnosis codes, including for comorbidities and complications, ICD-PCS procedure codes, and AIS codes for severity of illness and probability of survival, following applicable official guidelines and the AAAM AIS manual.

The role includes daily chart review and registry data entry for eligible patients, prompt reporting of complications and quality issues to the Trauma PI Coordinator, adherence to data management protocols for accurate and timely organizational and regulatory reporting, and assistance with performance improvement activities. Continued employment requires onboarding training and data validation scores of at least 95% accuracy after 12 months. CAISS certification is required within 24 months of hire.

Requirements

• One year of work experience in registry data abstraction or coding.
• Two years of experience in medical data abstraction or coding.
• Proficiency with MS Office, 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.
• Work experience specific to the role, such as in emergency medical services or a healthcare-related field, may be considered in lieu of credentials not required by law, subject to HR approval.
• Maintain data validation scores of at least 95% accuracy following 12 months of employment and fulfill onboarding training requirements.
• CAISS certification within 24 months of hire is required.

Nice To Haves

• Certification as a 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), or Paramedic (EMT-P).
• Experience in trauma or surgery registry abstraction or coding.
• Expert skills using Windows-based word processing, spreadsheet, and database software.
• Abstracting experience using current state and national regulatory body 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 control standards.
• 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.

Responsibilities

• Identify cases for trauma registry inclusion using the Master Patient Index, emergency department log, trauma log, and National Trauma Data Bank criteria.
• Abstract data from electronic medical records, prehospital databases, autopsy reports, and other sources that substantiate the injured patient.
• Assign ICD-10-CM diagnosis codes for diagnoses, comorbidities, and complications, and ICD-PCS procedure codes according to published Official Coding Guidelines.
• Assign and verify AIS codes for severity of illness and probability of survival using the AAAM manual for AIS coding.
• Conduct daily chart review and enter data into the Trauma Registry for patients meeting established criteria.
• Report complications and quality issues to the Trauma PI Coordinator as soon as they are discovered.
• Follow data management protocols to ensure accurate and timely reporting to the organization and regulatory agencies.
• Assist with performance improvement activities.
• Maintain data validation scores of at least 95% accuracy following 12 months of employment and fulfill onboarding training requirements.
• Obtain CAISS certification within 24 months of hire.

Benefits

• Competitive pay, incentives, and referral bonuses.
• 403(b) with employer contributions when eligible.
• Medical, dental, vision, and prescription coverage.
• HSA/FSA options.
• Life insurance.
• 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. Benefits may vary based on market and employment status.

What This Job Offers

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