Trauma Registrar
About The Position
The Trauma Registrar supports the VCU Health System’s adult or pediatric Trauma Programs and organizational requirements for verification as Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons by maintaining a registry database. This includes identification of cases for inclusion into the registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. The Trauma Registrar assigns ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities and complications according to methodologies and coding rules. This position performs on-going daily chart reviews on all patients and enters data into the Registry. The Trauma Registrar reports complications and quality issues to the Supervisor. 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
- Proficiency with MS Office software including email, MS-Word, and MS-Excel
- 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
- Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.
Nice To Haves
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification, or Registered Health Information Technician (RHIT) preferred
- Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 24 months of hire is required for Trauma Registrars
- 1 or more years of experience in medical data abstracting/coding
- Experience in trauma or surgery registry abstraction/coding depending on job assignment
- 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
- Completion of ICD-10 coding courses
Responsibilities
- Supports the VCU Health System’s adult or pediatric Trauma Programs and organizational requirements for verification as Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons by maintaining a registry database.
- Identifies cases for inclusion into the registry database.
- Abstracts data from various sources including the electronic medical record, prehospital databases, and other data sources.
- Assigns ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities and complications according to methodologies and coding rules.
- Performs on-going daily chart reviews on all patients and enters data into the Registry.
- Reports complications and quality issues to the Supervisor.
- Ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies.
- Assists with performance improvement activities.
- Performs daily chart reviews on specific patients.
- Assigns ICD-10 and other specialized codes and enters data into the registry.
- Interprets medical information.
- Is assigned patients of basic to moderate complexity including patients with multiple complications, including deaths.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
