Trauma Registrar

Job Title: Trauma Registrar

Job Location: Remote, VA

Duration: Full-Time

Shift Schedule:Day Shift

Summary:

The Trauma Registrar supports the Health System’s adult or pediatric Trauma Programs and organizational requirements for verification as a Level 1 Trauma Center by maintaining a registry database. This includes identification of cases for inclusion into the registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. The Trauma Registrar assigns ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities, and complications according to methodologies and coding rules. This position performs ongoing daily chart reviews on all patients and enters data into the Registry. The Trauma Registrar reports complications and quality issues to the Supervisor. The Trauma Registrar ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies. The Trauma Registrar assists with performance improvement activities.

Responsibilities:

• Perform daily chart reviews on specific patients.
• Assign ICD-10 and other specialized codes and enter data into the registry.
• Interpret medical information.
• Report complications and quality issues to the Supervisor.
• Ensure adherence to data management protocols for accurate and timely reporting of data.
• Assist with performance improvement activities.

Required Skills:

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification, or Registered Health Information Technician (RHIT) preferred.
• 1 or more years of experience in medical data abstracting/coding.
• Experience in trauma or surgery registry abstraction/coding depending on job assignment.
• Expert skills using Windows-based software (word processing, spreadsheet, databases).
• Abstracting experience using current requirements by state and national regulatory bodies.
• Experience with medical terminology and acronyms related to diagnosis, procedures, complications, and comorbid conditions.
• Experience with accurate and timely data entry and verification to maintain high standards of data quality control.