Trauma Registrar

Westchester Medical Center Health Network; Town of Mount Pleasant (NY); On-site; USD 45,000 - 70,000; Full time

Job summary

Westchester Medical Center Health Network seeks a Trauma Registrar to collect, abstract, code, and report data on traumatic injuries for the New York State Trauma Registry. The role involves reviewing medical records, identifying reportable cases, and entering data per program guidelines.

Responsibilities include quality control, producing routine and specialized reports for hospital leadership, and obtaining follow-up information as needed.

Qualifications

• Experience in healthcare and/or health information coding.
• Education: High school or equivalency diploma, required; Associates or Bachelor’s degree preferred.
• Licenses / Certifications: CPC, CSTR, CAISS preferred.
• Special Requirements: Knowledge of NYS Trauma Registry guidelines and ICD coding for trauma abstracting.

Responsibilities

• Reviews a variety of medical records to collect information related to trauma patients.
• Identifies records meeting NYS Trauma Registry criteria using ICD diagnosis and other criteria.
• Reads and interprets medical records to abstract and code for entry into the Trauma Registry Database.
• Prepares exclusion reports for Trauma Registry when appropriate.
• Researches additional information by contacting physicians or institutions.
• Obtains follow-up information for entry into the database.
• Maintains trauma data collection components per regulatory policies.
• Performs quality control to ensure data accuracy.
• Runs and distributes routine and specialized reports for hospital administration and staff.
• Participates in all Trauma Registry functions as required.

Skills

Healthcare experience

Health information coding

Education

High school diploma or equivalency

Associates or Bachelor’s degree preferred

Job description

Job Summary: Trauma Registar is responsible for collecting, abstracting, coding and reporting data regarding patients with traumatic injuries. Incumbent reviews medical records and communicates with trauma team staff to identify reportable cases and to collect information related to severity and cause of injury and course of care and outcome, and codes and enters the data into the New York State Trauma Registry database according to program guidelines.

Responsibilities

• Reviews a variety of medical records to collect information related to trauma patients
• Identifies patient records that meet criteria for inclusion in the New York State Trauma Registry, using ICD diagnosis and other criteria defined by the Registry
• Reads and interprets the various components of the medical record, such as physician documentation, radiology reports, laboratory reports and all treatment modalities, in order to abstract and code for entry into the Trauma Registry Database
• Prepares exclusion report for Trauma Registry when appropriate
• Researches additional information not given in medical record by, for example, contacting other physicians or institutions
• Obtains follow-up information for entry into database
• Maintains the components of the trauma related data collection system consistent with all regulatory and procedural policies
• Performs quality control activities and ensures accuracy of data
• Runs, compiles and distributes a variety of routine and specialized reports for hospital administration and staff
• Participates in all functions related to Trauma Registry, as required.

Qualifications/Requirements

Experience: Experience in healthcare and/or health information coding, along with a combination of education, training and experience that has supplied the necessary knowledge, skills and experience to perform the essential functions of the job, required.

Education: High school or equivalency diploma, required, Associates or Bachelor’s degree preferred.

Licenses / Certifications: CPC, CSTR ,CAISS preferred.

Special Requirements: Knowledge and understanding of the guidelines of the New York State Trauma Registry for trauma abstracting. Knowledge of medical terminology; good knowledge of the ICD codes; ability to read, understand and apply the appropriate guidelines for trauma abstracting; ability to accurately abstract and stage information from the various components of patient medical records; ability to understand and code medical records.