Remote Hospital Registrar

Network ESC; Richmond (VA); Remote; USD 65,000 - 90,000; Full time

Job summary

Private Medical Facility in the United States seeks a Trauma Registrar to coordinate and maintain the trauma registry across adult and pediatric cases, meeting Level I accreditation requirements.

Responsibilities include collecting data from EHRs, EMS reports, coding injuries with ICD-10 and AIS, and ensuring timely submission to agencies. This remote role follows East Coast time hours and emphasizes data accuracy and quality improvement.

Qualifications

• Minimum of one year of healthcare documentation or medical coding experience.
• Background in trauma registry data collection and coding is beneficial.
• Knowledge of healthcare terminology and medical abbreviations.
• Ability to apply ICD-10 codes and AIS scoring.

Responsibilities

• Review assigned patient charts daily to collect information for trauma registry documentation.
• Identify patients who meet criteria for entry into the trauma database.
• Gather information from EHRs, EMS reports, and other clinical resources.
• Apply ICD-10 codes and AIS scoring to documentation.

Education

CPC, CCS, RHIT or comparable medical coding credential

Tools

Microsoft Office

Database systems

Job description

Private Medical Facility is in need of Trauma Registrar Fully Remote East Coast Time Zone Monday through Friday Day Time Hours

Position Overview

The Trauma Registrar is responsible for assisting with the coordination and maintenance of the Health System’s adult and/or pediatric Trauma Registry to meet organizational standards and Level I Trauma Center accreditation and verification requirements.

This role involves locating qualifying trauma cases, gathering clinical information, and documenting patient data from various resources, including electronic health records, emergency medical service reports, prehospital documentation, and additional healthcare databases. The Registrar reviews medical records, evaluates clinical findings, and applies ICD-10 diagnosis codes and specialized classification systems, such as Abbreviated Injury Scale (AIS) scoring, to accurately document injuries, treatments, medical conditions, and complications.

Daily responsibilities include examining patient charts, collecting relevant clinical details, and maintaining complete and accurate records within the trauma database. The position also requires recognizing potential complications, reporting data discrepancies, and bringing patient care or documentation concerns to the attention of the Supervisor. Additionally, the Trauma Registrar participates in quality assurance and performance improvement initiatives.

The individual in this position must follow established data collection procedures, coding guidelines, and regulatory standards to ensure reliable documentation and timely submission of required information to healthcare organizations and governing agencies.

Education, Experience, and Skills

• CPC, CCS, RHIT, or another comparable medical coding or health information credential is preferred.

• Minimum of one year of experience in healthcare documentation, medical coding, or clinical record review.

• Background in trauma registry or surgical registry data collection and coding is beneficial, depending on the assigned department.

• Strong computer skills, including familiarity with Microsoft Office applications, spreadsheets, word processing programs, and database systems.

• Familiarity with state and national requirements governing medical record abstraction and registry reporting.

• Knowledge of healthcare terminology, medical abbreviations, diagnoses, surgical procedures, associated conditions, and patient complications.

• Ability to accurately collect, record, review, and validate medical information while maintaining consistency and data accuracy.

• Ability to understand clinical documentation and apply appropriate medical coding standards.

Primary Responsibilities

• Review assigned patient charts daily to collect information needed for trauma registry documentation.

• Identify patients who meet the criteria for entry into the trauma database.

• Gather and organize patient information from electronic health records, prehospital reports, and other clinical resources.

• Select and apply the appropriate ICD-10 codes and specialized injury classifications, including AIS scores.

• Examine medical documentation to identify diagnoses, injuries, treatments, existing medical conditions, and complications.

• Maintain and update registry records while ensuring information is complete, correct, and entered within required timeframes.

• Recognize reporting concerns, missing information, and potential patient care issues and notify the Supervisor when necessary.

• Follow established documentation practices, coding procedures, and applicable regulatory guidelines.

• Assist with departmental quality monitoring, data review, and trauma program improvement projects.

Independent Judgment and Case Complexity

The Trauma Registrar is expected to independently complete assigned medical record reviews, interpret patient information, determine appropriate coding, and maintain registry documentation.

Assigned cases typically range from routine to moderately complex and may involve patients with multiple traumatic injuries, additional medical conditions, serious complications, or death. The position requires attention to detail, the ability to evaluate clinical records, and the appropriate application of coding and data abstraction standards.