Senior Trauma Registrar

Overview

This job supports the VCU Health Trauma Program and organizational verification requirements for a Level 1 Trauma Center by maintaining the Trauma Registry. It involves identification of cases for inclusion, abstraction of data from the electronic medical record, prehospital databases, and other sources. The role assigns ICD-10 diagnosis codes and Abbreviated Injury Scoring (AIS) to injuries, procedures, comorbidities and complications according to coding rules, and performs ongoing daily chart reviews to enter data into the Trauma Registry.

It reports complications and quality issues to the Trauma Registry Operations Coordinator or Trauma Program Manager and ensures adherence to data management protocols for accurate and timely reporting to the organization and regulatory agencies. The position also assists with performance improvement activities and information requests.

• Identify cases for inclusion in the trauma registry database and abstract data from various sources (electronic medical record, prehospital databases, and other data sources).
• Assign ICD-10 diagnosis codes and Abbreviated Injury Scoring (AIS) to injuries, procedures, comorbidities, and complications using applicable coding rules.
• Perform ongoing daily chart reviews for all injured patients and enter data into the Trauma Registry.
• Report complications and quality issues to the Trauma Registry Operations Coordinator or Trauma Program Manager.
• Adhere to data management protocols to ensure accurate and timely reporting to the organization and regulatory agencies.
• Assist with performance improvement activities and respond to information requests.

• CAISS (Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring) or CSTR (Certified Specialist in Trauma Registry).

• 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).

• Required:
  
  Three (3) years of work experience in trauma registries or five (5) years of 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.

• One year of experience in trauma registry abstraction in an academic medical center; expert in ICD-10 and Abbreviated Injury Scoring.
• Experience analyzing data requests and creating moderate to complex reports from the registry.
• Excellent investigative/analytical skills with attention to detail; understanding of medical terminology and acronyms related to injuries and procedures.
• Experience analyzing data for accuracy and validating data for submission to national databases in a timely manner.
• Familiarity with IT hardware and software in LAN/WAN environments.

• Required:
  
  Associate 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.
• Note:
  
  Work experience may be considered in lieu of credentials where required by HR approval; work experience must be specific to the role.
• Preferred:
  Completion of ICD-10 coding courses.

• Willingness and ability to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.

• Physical:
  Lifting less than 20 lbs.
• Activities:
  
  Prolonged sitting
• Repetitive motion:
  Keyboarding, mouse
• Mental/Sensory:
  Strong recall, reasoning, problem solving, hearing, speaking clearly, writing legibly, reading, logical thinking
• Emotional:
  Steady pace, frequent and intense customer interactions, noisy environment, ability to adapt to frequent change

Performance Expectations:
Abstraction/Coding — Identifies reportable injuries; reviews and abstracts…