Trauma Registrar

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Graduated from an accredited program in Health Information Technology

OR

High School diploma anda minimum of 3 years' experience specific to the trauma Registry (Level 1 preferred).

2. Successfully complete AAAM coding course within 1 year of hire date.

3. Successfully completes ATS Trauma Registry course within 1 year of hire date.

EXPERIENCE:

1. Minimum one year work experience in a Health information management department.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Successful completion of the registered health information technicians (RHIT) or Registered Health Information Administrator (RHIA) certification exam is preferred.

EXPERIENCE:

1. Previous experience with trauma registry/database systems is preferred.

2. Familiarity with ICD-9, ICD-10, AAAM coding, AIS/ISS scoring, TRISS is preferred

CORE DUTIES AND RESPONSIBILITIES:The statements described here are intended to describe the general nature of work being performed by people assigned to this position.They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.Other duties may be assigned.

1. Daily reviews the system report logs of the Emergency Department, Operating room schedule, and Hospital admissions report for patients that meet criteria for inclusion in the Trauma Registry.

2. Reviews, analyzes, and interprets information and data on all identified Trauma Registry patients from numerous sources to identify injuries, procedures, complications, and other pertinent trauma registry data.

3. Assumes primary responsibility for concurrent data collection on specified data points.

4. Requests and obtains financial information, including hospital charges, hospital collections, and financial classification from financial services.

5. Reviews, analyzes, and interprets data from all available patient information systems including. staff and nursing progress notes and flow sheets, written and dictated anesthesia and operative notes, laboratory and blood bank reports, x-ray and other diagnostic radiographic findings, physical therapy, occupational therapy, speech therapy, and neuropsychiatric progress notes, pathology reports, and autopsy/post mortem data.

6. Reviews and updates all in-patient charts on a daily basis when at all possible.

7. Accurately assigns appropriate codes for all collected information. FIPS Codes, Hospital, Ambulance, and staff Codes, E-Codes, ICD-9 / 10 -CM codes for procedures and injuries, and complication codes.

8. Accurately enters collected data into the Collector Trauma Registry. Identified patients are entered into the Trauma Registry on a daily basis.

9. Meets data completion requirements to facilitate daily, weekly, and monthly Quality improvement activities.

10. In collaboration with the Trauma Program Manager and Trauma Medical Director, ensures compliance with all registry related Level 1 Trauma Center Designation criteria.

11. Provides statistical reporting via downloaded Collector Trauma Registry data to the West Virginia State Trauma and Emergency Care System for inclusion into the State Trauma Registry on a monthly basis. Compiles and submits registry data to the TQIP on a Quarterly and as called for basis. Compiles and submits registry data to TQIP on a quarterly basis.

12. Participates as an integral member of the Multidisciplinary Trauma Performance improvement and patient safety Program. Assists in report generation and registry data validation at all meetings.

13. Represents the Jon Michael Moore Trauma Center in State and National Meetings regarding the Trauma Registry.

14. Reviews requested trauma data with Trauma Program Manager and Trauma Medical Director to assure compliance with Internal Review Board (IRB) for Investigational Study requirements. Provides data and statistical information for trauma research, education and outreach and provides studies and audits for other research activities as requested by physicians and supervisors.

15. Participates in professional development to assure skills and knowledge of trauma data information. Requires a minimum of 8 hours of pertinent continuing education hours annually, seeks opportunities to advance trauma knowledge base, and participates in the training of additional Trauma Registry personnel.

16. Assumes primary responsibility for accurate and concurrent Trauma Registry data. The data is utilized for injury research, epidemiology and quality improvement activities within the Jon Michael Moore Trauma Center.

17. Responsible for obtaining, abstracting, correcting and entering appropriate patient data, both concurrently and retrospectively on all trauma patients, in order to maintain an accurate/concurrent trauma patient data base for the Trauma Program.

18. Responsible for compiling statistics, preparing reports, generating reports on trauma populations and performing data searches for trauma related research projects.

19. Must complete data collection with 95% accuracy.

PHYSICAL REQUIREMENTS:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to keypunch data for sustained periods of time.

2. Ability to lift 11 to 20 pounds

WORKING ENVIRONMENT:The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Detail oriented with the ability to organize/complete work under deadlines. Demonstrated proficiency in Collector Software and the EPIC electronic medical record application.

2. A working knowledge of trauma, medical terminology and anatomy is highly desirable.

3. Under general direction must be able to work independently, adapt quickly to change and perform all responsibilities of the trauma registrar.

4. Good communication skills (oral and written)/Must be able to interact appropriately with professional staff.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

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Cost Center: