SJCH Trauma Registrar II

Medical University of South Carolina; Charleston (SC); On-site; USD 60,000 - 80,000; Full time

Job summary

The Medical University of South Carolina is seeking a Trauma Registrar II to manage the trauma registry, ensuring accurate data collection and coding according to established guidelines. The ideal candidate will possess a strong background in medical terminology and coding, along with effective interpersonal skills to interact with the trauma team. This role plays a crucial part in maintaining compliance with various guidelines and improving trauma care quality through accurate reporting and data analysis.

Qualifications

• Completion of a medical terminology course.
• Knowledge of basic anatomy.
• Certified Coding Certificate (CCA) or CPC required at hire.

Responsibilities

• Collect and maintain data for trauma registry.
• Perform ICD-10-CM and AIS coding.
• Participate in quality assurance and improvement activities.

Skills

Medical terminology

Data analysis

Interpersonal skills

Education

High school diploma

Medical records ICD-10-CM and CPT-4 coding class

Associate degree

Job description

Job Description Summary

The Trauma Registrar II collects, compiles, and maintains complete and accurate data on patients meeting inclusion criteria for entry into the trauma registry data system, according to the requirements of the American College of Surgeons, the National Trauma Data Standard, and the SC Department of Public Health. This role performs ICD-10-CM and AIS coding for all patients entered into the trauma registry.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type

Regular

Cost Center

CC000598 CHS - Pediatric Trauma (SJCH)

Pay Rate Type

Hourly

Pay Grade

Health-25

Scheduled Weekly Hours

40

Work Shift

Day (United States of America)

Job Description

Job Responsibilities:

Identifies trauma patients in EMR (EPIC) and performs basic data collection of demographics, and coding of clinical and follow-up data from all sources into the trauma registry to maintain a concurrent database.

Success Criteria:

Interacts with physicians, nurses, and other members of the trauma team to perform trauma registry functions.

Collaborates with Trauma Program Manager to abstract patient complication and/or co-morbidity according to National Trauma Data Dictionary description and ABA inclusion criteria.

Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.

Maintains concurrency of the trauma registry to meet the ACS requirement of closing charts within 60 days of patient discharge.

Success Criteria:

Completion of data abstraction and closure of registry records for discharged patients will be concurrent with a minimum of 80% of the cases being closed within 60 days of patient discharge.

Abstracts, assembles, enters, and codes clinical data with 95% accuracy into computer database by using the Association for the Advancement of Automotive Medicine Abbreviated Injury Scale (AIS), ICD-10-CM, 3 M and the Registry Users Operations and Standards Manual.

Success Criteria:

Resolves routine coding issues/problems and appropriately seeks assistance from the Trauma Program Manager for the more difficult ones.

Performs monthly audit of trauma registry through inter-rater reliability, single variable, and multi-variable logic variable levels.

Participates in quality assurance and improvement activities to ensure accuracy of data collection and timely submission of data according to South Carolina State Trauma Registry, the American College of Surgeons (ACS) Optimal Guidelines for Trauma Centers.

Success Criteria:

Submits data to the State Trauma Registry and the Trauma Quality Improvement Program (TQIP) quarterly.

Collaborates with Trauma Medical Director, Trauma Program Manager, and the PI Coordinator to analyze quality and benchmarking performance outcomes defined in the Spring and Fall annual TQIP reports.

Assists with development of performance improvement strategies to address quality or performance concerns.

Participates in Trauma Performance Improvement and ACS Committee meetings and educational conferences in order to maintain and expand Trauma Registry knowledge base.

Success Criteria:

TQIP/ATS Registry Webinars

Applicable registry training courses

Provides necessary registry data to assist with internal and external injury prevention outreach, education, and research efforts.

Success Criteria:

Provides registry reports to hospital personnel as requested.

Additional Job Description

Job Requirements:

Completion of a medical terminology course and knowledge of basic anatomy Completion of the American Trauma Registrar Course – Basic and Advanced, ICD-10 coding course and AIS Course. Understanding of quality assurance and performance improvement as well as effective interpersonal skills is essential. Knowledge of data analysis and report writing preferred

High school diploma and completion of a medical terminology course and a medical records ICD-10-CM and CPT-4 coding class and one year related experience;

an Associate degree may be substituted for the required work experience.

Certified Coding Certificate (CCA) or Certified Professional Coder (CPC), and /or Certified Trauma Registrar (CSTR) required at the time of hire and must be maintained.

Physical Requirements:

1) (C) Continuous – 6-8 hours per shift; 2) (F) Frequent – 2-6 hours per shift; 3) (I) Infrequent – 0-2 hours per shift Ability to perform job functions while standing. (C). Ability to perform job functions while sitting. (C) Ability to perform job functions while walking. (Continuous) Ability to climb stairs. (I) Ability to work indoors. (C) Ability to work outside in temperature extremes. (I) Ability to work from elevated areas. (F) Ability to work in confined/cramped spaces. (F) Ability to perform job functions from kneeling positions. (I) Ability to bend at the waist. (C) Ability to twist at the waist. (F) Ability to squat and perform job functions. (F) Ability to perform “pinching” operations. (F) Ability to perform gross motor activities with fingers and hands. (C) Ability to perform firm grasping with fingers and hands. (C) Ability to perform fine manipulation with fingers and hands. (C) Ability to reach overhead. (F) Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (C) Ability to fully use both legs. (C) Ability to use lower extremities for balance and coordination. (F) Ability to reach in all directions. (C) Ability to lift and carry 50 lbs. unassisted. (I) Ability to lift/lower objects 50 lbs. from/to floor from/to 36 inches unassisted. (I) Ability to lift from 36” to overhead 25 lbs. (I) Ability to exert up to 50 lbs. of force. (F) Examples include: To transfer a 100 lb. patient that can not assist in the transfer requires 50 lbs. of force. For every 100 additional pounds, assistance will be required from another healthcare worker. 20 lbs. of force is needed to push a 400 lb. patient in a wheelchair on carpet. 25 lbs. of force is required to push a stretcher with a patient with one hand. Ability to maintain vision 20/40 corrected. (C) Ability to see and recognize objects close at hand or at a distance. (C) Ability to match or discriminate between colors. (C) Ability to determine distance/relationship between objects; depth perception. (C) Good peripheral vision capabilities. (C) Ability to maintain hearing acuity, with correction. (C) Ability to perform gross motor functions with frequent fine motor movements. (C) Ability to deal effectively with stressful situations. (C) Ability to work rotating shifts. (F) Ability to work overtime as required. (F) Ability to work in a latex safe environment. (C) *Ability to maintain tactile sensory functions. (C) *(Selected Positions) *Ability to maintain good olfactory sensory function. (C) *(Selected Positions) *Ability to be qualified physically for respirator use, initially and as required. (C) (Selected Positions)

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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