Trauma Registrar

VCU Health • Richmond, VA

2d

About The Position

The Trauma Registrar supports VCU Health System’s adult or pediatric Trauma Programs and organizational requirements for verification as a Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons. The role maintains a trauma registry database by identifying cases for inclusion and abstracting data from sources such as the electronic medical record, prehospital databases, and other data sources. The registrar assigns ICD-10 diagnosis codes and specialized codes, including Abbreviated Injury Scale (AIS) scores, to procedures, comorbidities, and complications in accordance with applicable methodologies and coding rules.

The position performs ongoing daily chart reviews, enters data into the registry, reports complications and quality issues to the Supervisor, and follows data-management protocols to support accurate and timely reporting to the organization and regulatory agencies. The Trauma Registrar also assists with performance improvement activities. The registrar handles assigned patients of basic to moderate complexity, including patients with multiple complications and deaths, and must be willing and able to work evenings and weekends when needed based on case volumes and verification site surveys.

Requirements

• 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. Work experience may be considered in lieu of credentials not required by law with HR approval and must be specific to the role.
• Proficiency with MS Office software, including email, MS Word, and MS Excel.
• 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.
• Ability to work evenings and weekends when necessary based on case volumes and state or national verification site surveys.
• Physical ability to lift less than 20 lbs.; prolonged sitting; repetitive keyboarding and mouse use.
• Strong recall, reasoning, problem-solving, hearing, clear speech, legible writing, reading, and logical thinking; ability to work at a fast or steady pace and adapt to frequent change.

Nice To Haves

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), equivalent coding certification, or Registered Health Information Technician (RHIT).
• One or more years of experience in medical data abstracting or coding.
• Experience in trauma or surgery registry abstraction or coding, depending on job assignment.
• Expert skills using Windows-based word-processing, spreadsheet, and database software.
• Abstracting experience using current requirements of state and national regulatory bodies.
• 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 standards.
• Completion of ICD-10 coding courses.

Responsibilities

• Identify cases for inclusion in the trauma registry.
• Abstract data from electronic medical records, prehospital databases, and other data sources.
• Assign ICD-10 diagnosis codes and specialized codes, including AIS scores, to procedures, comorbidities, and complications according to coding methodologies and rules.
• Perform daily chart reviews on assigned patients and enter data into the registry.
• Interpret medical information.
• Report complications and quality issues to the Supervisor.
• Follow data-management protocols to ensure accurate and timely reporting to the organization and regulatory agencies.
• Assist with performance improvement activities.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree