Trauma Registrar II

The best thing about this role

Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible.

The Trauma Registrar II general supervision identifies and abstracts trauma cases from the medical record for inclusion in the trauma registry in accordance with American College of Surgeons standards, NYS DOH and other accreditation bodies; communicates with EMS agencies regarding collection of missing trauma related pre-hospital data; abstract data from the patient’s chart and accurately enter data into the appropriate computerized database in a timely manner;

verify completeness and integrity of registry data; assist in preparation of trauma information for submission to the NYS DOH and other appropriate regulatory agencies; assist in preparation of reports as requested; use word processing and spreadsheet applications for communication and record keeping; participate in trauma department’s PIPS, QI/QA, and trauma or other related registry conferences as requested; provide assistance with ATLS, TNCC, ENPC courses and EMS education activities;

maintain confidentiality of trauma related activities and attend Local or State meetings as required.

• Accurately abstracts trauma injury, diagnosis, operative and other pertinent data from patient records
• Abstracts clinical data from patient records including pre-hospital, Emergency Department and transfer patient information
• Communicates with outside agencies for missing data
• Identifies potential trauma related care issues and provides appropriate feedback to Trauma Program Manager, Trauma Program Director or other staff monthly as indicated
• Identifies potential coding errors and reports them as indicated
• Assists Trauma Program Manager with reports as requested
• Reviews actual documentation on trauma patients for accuracy and completeness while abstracting data
• Assists with development and implementation of quality management program for trauma services
• Maintains the trauma registry and is up to date 90-95% of the time as measured by the Manager on a yearly basis
• Maintains the Bassett Trauma Registry by collecting, reviewing, and entering data of patients each year as tracked by the registry
• Maintains trauma logs
• Maintains confidentiality and security of all patient information in compliance with hospital and federal regulations
• Uses quality data to identify potential issues, trends and educational opportunities
• Submits timely data to appropriate agencies (NYSDOH, NTDB, TQIP)
• Generates and runs reports for QA/PI as required or requested to facilitate continued education and system improvement
• Minimum of eight (8) hours of continuing education pertaining to quality management of trauma program
• Participates at NY State Trauma Advisory Committee (STAC) and Regional Advisory Trauma Committee (RTAC)
• Participates in STAC registrar sub-Committee meetings and attends general session. Supports research projects as requested
• Participates in RTAC meetings and regional PI as required
• Builds relationships with other trauma professionals within the state system
• Provides program support for injury prevention and EMS education
• Participates in local prevention programs as needed
• Assists with EMS education programs as needed
• Performs administrative duties as needed
• Performs other duties as requested and observed by supervisor or manager

Education:

• High School Diploma/GED, preferred
• 2 Year/Associate Degree, preferred
  • Associates may be used towards 1 year of experience

Experience:

• Experience with computer data entry, databases and spreadsheets, required
• Minimum 1 year work experience as a trauma registrar, preferred
• Experience with International Classification of Diseases (ICD-10) and CPT coding and billing, preferred
• Experience with Abbreviated Injury Scale/Injury Severity Scores (AIS/ISS)
• Experience with the institutional trauma registries and electronic medical records, preferred

Licensure/

Certifications:

• Certified…