Trauma Registrar

University of Utah Health•Salt Lake City, UT

6d•Hybrid

About The Position

The Trauma Registrar is responsible for the traumatic injured patient identification, collection, entry, validation and maintenance of injury data for our American College of Surgeons (ACS) verified Level 1 Trauma Center. Utilizing analytical and cognitive skills, the Trauma Registrar collects trauma data used for improvement in clinical care, injury research, national benchmarking, epidemiology, prevention and quality initiatives, performance improvement, and education. The registry professional accurately assigns ICD-10 and AIS codes and enters required data into the trauma registry, maintaining HIPAA standards at all times.

Requirements

Trauma Registry OR verified ICD10 coding experience or certification(s).
One (1) year of experience abstracting medical information from EMR.
Ability to participate in and pass the Abbreviated Injury Scale (AIS) course within one (1) year of hire.
Ability to participate in and pass the American Trauma Society (ATS) Trauma Registry Course within one (1) year of hire.
Complete 24 hours of trauma-related Continuing Education during each ACS verification cycle.
Completes ICD-10 refresher course every five (5) years.
Obtains Certified Abbreviated Injury Scale Specialist (CAISS) within five (5) years of hire.

Nice To Haves

Preferred Trauma Registry experience.
Current CCA, CCS, CPC, RHIT or RHIA Certification.
One (1) year of inpatient coding experience.
Certified Specialist in Trauma Registries (CSTR).
Certified Abbreviated Injury Scale Specialist (CAISS).
Associate or Bachelor degree in a related field.

Responsibilities

Participates in all registry-required activities to maintain ACS Verification as a Level 1 Trauma Center.
Performs thorough review of electronic medical record (EMR) for identification of relevant clinical diagnoses, procedures performed, complications, co-morbidities, and other pertinent EMS and hospital data as required by the ACS.
Assigns appropriate ICD-10-CM diagnosis, and ICD-10 PCS codes based on currently published standards.
Collaborates with appropriate entities to assure complete documentation for all required registry data fields.
Understands and adheres to Official AIS Coding and AAAM coding policies based on currently published standards.
Understands and adheres to National Trauma Data Standard (NTDS) data dictionary definitions on current year required data fields.
Accurately abstracts pertinent data from the patient medical records, and applied ICD-10 and AIS coding at greater than or equal to 95% accuracy.
Completes 100% of records within 60 days of patient discharge.
Participates in re-abstraction/validation of 5-10% of patient records with inter-rater reliability of 95% or greater.
Prepares, and distributes a daily list of identified trauma patients to pertinent UUH staff.
Prioritizes completion of data on all trauma related mortalities for Trauma Review Committee meetings.
Assigns appropriate activations charges based on current criteria.
Participates in data reporting for statistics, quality and performance improvement projects, grant submissions, and IRB approved research studies.
Assists in preparing data for submission to the State of Utah Department of Health.
Assists in preparing quarterly data for submission to the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP).
Participates in monthly ACS-TQIP educational quizzes, internal education, and any additional training as needed.
Participates in quarterly State of UT Trauma User Group (UT-TUG) meetings, periodic trainings, and on ad-hoc committees.
Completes twenty-four (24) hours of trauma-related Continuing Education during each ACS verification cycle.
Participates in trauma related quality initiatives.