Trauma Registrar

Virginia Commonwealth University Health Systems; Richmond (VA); On-site; USD 34,000 - 54,000; Full time

Job summary

Virginia Commonwealth University Health Systems is seeking a Trauma Registrar to support adult and pediatric trauma programs and verification efforts for Level 1 status. You will identify cases, abstract data from EHRs and other sources, and assign ICD-10 and AIS codes for procedures, comorbidities and complications.

Responsibilities include daily chart reviews, entering data into the registry, reporting quality issues to the supervisor, and supporting performance improvement activities.

Qualifications

• Associate's Degree including two semesters of medical terminology and Anatomy/Physiology.
• Work experience in medical data abstracting or coding is preferred.

Responsibilities

• Performs daily chart reviews and assigns ICD-10 and other specialized codes.
• Interprets medical information and enters data into the registry.
• Maintains data quality and adheres to data management protocols.
• Supports performance improvement activities and reports to supervisor.

Skills

MS Office

Medical data abstracting

Medical terminology

ICD-10 coding basics

Education

Associate's Degree including medical terminology and Anatomy/Physiology or medical records coding

ICD-10 coding courses (preferred)

Tools

Windows-based software

Job description

The Trauma Registrar supports the VCU Health System's adult or pediatric Trauma Programs and organizational requirements for verification as Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons by maintaining a registry database. This includes identification of cases for inclusion into the registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. The Trauma Registrar assigns ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities and complications according to methodologies and coding rules. This position performs on-going daily chart reviews on all patients and enters data into the Registry. The Trauma Registrar reports complications and quality issues to the Supervisor. The Trauma Registrar ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies. The Trauma Registrar assists with performance improvement activities.

Licensure, Certification, or Registration Requirements for Hire:

• Certified Professional Coder (CPC)
• Certified Coding Specialist (CCS)
• or equivalent coding certification
• or Registered Health Information Technician (RHIT) preferred

Licensure, Certification, or Registration Requirements for continued employment:

• Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 24 months of hire is required for Trauma Registrars, Incumbents not involved in direct patient care may continue to work while awaiting test results for up to 45 days, post 24/18 month requirement

Experience REQUIRED:

• Proficiency with MS Office software including email, MS-Word, and MS-Excel

Experience PREFERRED:

• 1 or more years of experience in medical data abstracting/coding
• Experience in trauma or surgery registry abstraction/coding depending on job assignment
• Expert skills using Windows-based software (word processing, spreadsheet, databases)
• Abstracting experience using current requirements by state and national regulatory bodies
• Experience with medical terminology and acronyms related to diagnosis, procedures, complications and comorbid conditions
• Experience with accurate and timely data entry and verification to maintain high standards of data quality control

Education/training REQUIRED:

(Note: work experience may be considered in lieu of credentials not required by law with HR approval. Work experience must be specific to role)

• Associate's Degree in any field that includes two semesters of medical terminology and Anatomy/Physiology, or in medical records coding from an accredited program

Education/training PREFERRED:

• Completion of ICD-10 coding courses

Independent action(s) required:

• Performs daily chart reviews on specific patients.
• Assigns ICD-10 and other specialized codes and enters data into the registry.
• Interprets medical information.
• The Registrar is assigned patients of basic to moderate complexity including patients with multiple complications, including deaths.

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: Fast pace environment, Steady pace, Able to adapt to frequent change

Compensation Range

$25.03 - $38.79

Actual salary offers will be based on several key factors to include relevant work experience, credentials, and qualifications.