Trauma Registrar

Cleveland Clinic•Mayfield Heights, OH

1d•Hybrid

About The Position

Join Cleveland Clinic and experience world-class healthcare at its best. Cleveland Clinic Hillcrest Hospital is a proud Magnet Hospital awarded by the American Nurses Credentialing Center, the highest honor an organization can receive for professional nursing practice. Here, you will work alongside a dedicated team of caregivers, receive endless support and appreciation, and build a rewarding career. As a Trauma Registrar, you will abstract and code medical record data for trauma patients according to guidelines established by the American College of Surgeons Trauma Quality Improvement Program (TQIP), the State of Ohio Trauma Registry and the regional trauma system. In this role, you will identify patients who meet trauma registry criteria, review and abstract information from medical charts, and collect, abstract and enter data into the trauma registry. You will assign ICD-9/ICD-10 codes, Injury Severity Scores (ISS), Abbreviated Injury Scale (AIS) codes, E-Codes and trauma scores. You will also perform reporting activities, audit other registrars’ work and submit data to state and national organizations. This role is highly data-driven, with a strong emphasis on registry management, data abstraction and accuracy. A caregiver in this role works a hybrid schedule from 7:00 a.m. – 3:30 p.m. (flexible hours) with three days onsite per week during designated periods.

Requirements

Complete 8 hours of trauma registry related continuing education per year as recommended by the American College of Surgeons
Within one of hire, obtain required certifications/education as directed by the American College of Surgeons (Includes AAAM AIS, trauma registry and ICD 10 (or updated versions)
Knowledge and skills using EPIC and Excel

Nice To Haves

Associate degree in Health Care or equivalent work experience of at least two years, including medical terminology
Certified Specialist in Trauma Registry (CSTR), Registered Information Technician (RHIT), or Certified Coding Specialist (CCS)
Previous data registry experience including knowledge in case abstraction, data entry, ICD-9 or ICD-10 coding, and AIS/ISS scoring
Trauma Registrar experience
Medical coding experience
Coding knowledge

Responsibilities

Identify patient records for entry into the trauma registry.
Collect, abstract, and accurately enters trauma patient information into the trauma registry in a timely manner.
Complete final entry of patient data no later than 60 days post discharge.
Participate in data validation and maintain department standards.
Comply with all internal/external reporting requests and requirements.
Assist in the preparation for American College of Surgeons trauma center verification.
Ensure data is abstracted and submitted to meet the American College of Surgeons and State of Ohio data submission deadlines.
Chart closures according to the American College of Surgeons guidelines.
Other duties as assigned.