This job supports the VCU Health Trauma Program and organizational requirements for verification as a Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons Committee on Trauma by maintaining a unique database called the Trauma Registry. This includes identification of cases for inclusion into the trauma registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. This job assigns ICD 10 diagnosis codes and Abbreviated Injury (AIS) Scores to injuries, procedures, comorbidities and complications according to ICD-10 and Abbreviate Injury Scoring methodologies and coding rules. This job performs on-going daily chart reviews on all injured patients and enters data into the Trauma Registry. This job reports complications and quality issues to the Trauma Registry Operations Coordinator or Trauma Program Manager. This job ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the Organization and regulatory agencies. This job also assists with performance improvement activities and information requests.
Licensure, Certification, or Registration Requirements for Hire: Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS) or Certified Specialist in Trauma Registry (CSTR)
Licensure, Certification, or Registration Requirements for continued employment:
Certified Specialist in Trauma Registry (CSTR) must be obtained within 6 months of hire Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS)
Experience REQUIRED:
Three (3) years of work experience in trauma registries or five (5) years experience in medical data abstraction/coding
Abstracting experience using current requirements by state and national regulatory bodies
Expert proficiency with Windows-based and MS Office software including email, MS-Word, and MS-Excel and databases
Experience PREFERRED:
One year of experience in trauma registry abstraction in an academic medical center Expert at ICD-10, Abbreviated Injury and Injury Severity Scoring
Experience analyzing requests for data and creating moderate to complex reports from the registry
Excellent investigative/analytical skills with detail orientation
Understanding of medical terminology and acronyms related to accurate identification and coding of injuries and procedures
Experience analyzing data for accuracy and validating data for submission to national databases in a timely manner
Familiarity with information technology hardware and software in a local and wide area network environment
Education/training REQUIRED:
Associates Degree in a healthcare-related field or in medical records coding including at least two semesters of human anatomy/physiology and medical terminology from an accredited program
Education/training PREFERRED: Completion of ICD-10 coding courses
Independent action(s) required:
Performs daily chart reviews on injured patients.
Assigns ICD-10 and Abbreviated Injury codes and enters data into the trauma registry.
Interprets medical information. Supports the ongoing initiatives of the Trauma Center leadership.
The Trauma Registrar-Sr. is assigned patients of moderate to high complexity including patients with multi-system injuries, multiple procedures and complications and deaths.
Serves as a liaison between the Trauma Center leadership and the trauma registry team and other hospital committees or groups.
Supervisory responsibilities (if applicable): N/A
Additional position requirements:
Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.
Age Specific groups served: N/A
Physical Requirements (includes use of assistance devices as appropriate):
Physical: Lifting less than 20 lbs.
Activities: Prolonged sitting
Repetitive motion: Keyboarding, Mouse
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional: Steady pace, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change
EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.