Trauma Registrar (Remote)

Medical University of South Carolina

1d•Remote

About The Position

The Trauma Registrar reports to the Trauma Registry Manager. Under general supervision, the Trauma Registrar is responsible for electronically administrating the Trauma Registry Data System in accordance with the requirements of the American College of Surgeons and South Carolina Department of Public Health (DPH). This position is also responsible for collecting, compiling, reporting, maintaining and entering accurate and complete data relative to current ICD-CM and AIS coding for the trauma registry. This is a remote position. Entity Medical University Hospital Authority (MUHA)

Requirements

High school diploma with experience in medical terminology required.
A medical records course to include ICD-CM or AIS and one year related experience, or Associate degree in coding, preferred.
Experience in data entry preferred.
Familiarity with chart abstraction helpful.

Nice To Haves

Experience with EPIC electronic medical record and Image Trend Patient Registry is helpful.
Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Abbreviated Injury Scale Specialist (CAISS) and/or Certified Trauma Registrar (CSTR) preferred.

Responsibilities

Collect, compile and maintain concurrent accurate data in the Trauma Registry.
Ensure accurate current AIS/ICD-CM coding required by the National Trauma Data Bank, American College of Surgeons and the Abbreviated Injury Scaling system on all trauma patients.
Maintain daily trauma database of patients admitted to MUSC meeting the National Trauma Data Bank and South Carolina DHEC inclusion criteria.
Abstract and analyze information from Epic, EMS Patient care records, outside hospital transfer records and any other sources of documentation that may be available to capture accurate patient information into the Trauma Registry.
Demonstrate knowledge of current ICD-CM, AIS, Glasgow Coma Scale, Revised Trauma Score, Probability of Survival and Trauma and Injury Severity score.
Demonstrate knowledge of anatomical and medical terminology used frequently with trauma patients.
Collaboration to help improve TQIP scoring and performance improvement.
Identify, document and discuss complications, PI issues, and noted variances in data while reviewing and analyzing charts.
Report identified issues and trends directly to the department’s management.
Analyze and identify errors and omissions in data entry using Inter-Rater Reliability.