Trauma Registrar

CommonSpirit Health•Merced, CA

1d•Onsite

About The Position

As our Trauma Registrar, you will accurately abstract and enter data from patient records into the Trauma Patient Registry. Your meticulous work ensures a consistent and reliable trauma database, vital for program evaluation. Every day you will abstract data from complex patient records, applying AIS and ICD-10 injury coding for accurate entry. You'll work closely with the Trauma Program Manager, ensuring database integrity and quality. To be successful, you will be self-motivated, with meticulous attention to detail and high accuracy. Strong proficiency in AIS and ICD-10 coding, excellent organizational skills, and a commitment to data quality are essential. Performs basic data collection of demographics, and coding of clinical and follow-up data from all sources into the trauma registry database. Interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions, complete registry entry within 60 days of patient discharge, and forward data to various reporting agencies as instructed. Abstracts, assembles, enters and codes clinical data and verifies accuracy using the Trauma Data Quality Plan Resolves routine coding issues/problems and appropriately seeks assistance from Trauma Program Manager for the more difficult ones Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information Participates in Trauma Performance Improvement and ACS Committee meetings and educational conferences in order to maintain and expand Trauma Registry knowledge base Participate in internal and community outreach education on injury prevention, trauma systems, and trauma data and meets ACS Trauma Registrar requirements

Requirements

High School Graduate General Studies and requires at least one (1) year of Patient Care Assistant, Administrative Assistant, or Medical/Clerical experience, preferably in a healthcare setting
High School GED General Studies and requires at least one (1) year of Patient Care Assistant, Administrative Assistant, or Medical/Clerical experience, preferably in a healthcare setting
Trauma Registrar must be a Certified Abbreviated Injury Scale Specialist (CAISS) within one (1) year of hire/transfer unless one is already in place, or Must meet Trauma Registry Course and Continuing Education requirements set forth by ACS within one (1) year of hire/transfer

Nice To Haves

Knowledge of various software packages
Data entry skills
Knowledge of basic anatomy, ICD-CM coding, E-codes, Injury Severity Scoring and Probability of Survivability
Understanding of quality assurance and performance improvement
Effective interpersonal skills
Knowledge, understanding, acceptance, and support of the philosophy, objectives, and policies of the Department of Surgery Trauma Service, and Health System
Successfully complete the exam and have knowledge of basic human anatomy
Experience with data analysis and report writing is strongly preferred

Responsibilities

Accurately abstract and enter data from patient records into the Trauma Patient Registry.
Abstract data from complex patient records, applying AIS and ICD-10 injury coding for accurate entry.
Work closely with the Trauma Program Manager, ensuring database integrity and quality.
Performs basic data collection of demographics, and coding of clinical and follow-up data from all sources into the trauma registry database.
Interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions, complete registry entry within 60 days of patient discharge, and forward data to various reporting agencies as instructed.
Abstracts, assembles, enters and codes clinical data and verifies accuracy using the Trauma Data Quality Plan.
Resolves routine coding issues/problems and appropriately seeks assistance from Trauma Program Manager for the more difficult ones.
Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.
Participates in Trauma Performance Improvement and ACS Committee meetings and educational conferences in order to maintain and expand Trauma Registry knowledge base.
Participate in internal and community outreach education on injury prevention, trauma systems, and trauma data.