Trauma Registrar

Brown Medicine; États-Unis; À distance; USD 33 000 - 55 000; Plein temps

Résumé du poste

Brown University Health is seeking a Trauma Registrar to collect, abstract, and enter clinical data for admitted trauma patients into the TraumaOne database. You will code injuries using ICD-10 and AAAM systems, and ensure timely entry and high accuracy, supporting Joint Commission and ACS verification standards.

Responsibilities include data validation, dictionary updates, and collaboration with the Trauma Program Manager to improve efficiency.

Qualifications

• Solid knowledge of anatomy and medical terminology.
• Experience with ICD-10-CM coding and data abstraction.

Responsabilités

• Collect, abstract and enter clinical data for admitted trauma patients into the TraumaOne database following policy.
• Identify and enter patients using trauma database inclusion criteria.
• Assign diagnoses and procedures using ICD-10 and AAAM coding systems.
• Ensure 80% of cases are completed within 60 days of discharge.
• Maintain 95% accuracy on data validation.
• Update data dictionaries and reference documents.
• Collaborate to maximize efficiency of data abstraction and report gaps.
• Prepare for ACS site visits.
• Work with the health care team to support trauma division goals.
• Engage in ongoing professional development in trauma data systems.
• Comply with all policies and procedures.

Connaissances

Medical terminology

Anatomy knowledge

ICD-10-CM

Database management

Microsoft Office

Formation

High School diploma

Associate/Bachelor in Medical Record Management or related health science

Trauma Registrar course

AIS certification

CCA/CCS certification desirable

Outils

TraumaOne database

Description du poste

Job Description

SUMMARY:

The Trauma Registrar is an integral member of the Trauma Registry. As the only ACS verified Level I Trauma Center in the state, we provide essential trauma care to over 4,200 patients admitted with traumatic injuries every year. The Trauma service relies on the Trauma Registry to support the performance improvement process that is integral to our hospital’s American College of Surgeons verification status. Under the direction of the Trauma Program Manager, the registrar assures accurate, timely, and comprehensive data collection, coding and entry into the TraumaOne database.

The chief responsibility of a registrar is to enter into the TraumaOne database the documented injuries and care provided to trauma patients admitted to the hospital.

RESPONSIBILITIES:

Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect, and Excellence as these guide our everyday actions with patients, customers and one another.

• Primary role is the collection, abstraction and entry of clinical data of admitted trauma patients. The data will be accurately and timely entered into the TraumaOne database following the Data Entry Policy within the Trauma Registry. This activity ensures the hospital is in compliance with all standards as they relate to Joint Commission, American College of Surgeons, National Trauma Data Bank (NTDB) and American Burn Association.
• Utilizing trauma database inclusion criteria, the registrar identifies and enters patients into the trauma database.
• Assign diagnosis and procedural codes to trauma patient’s injuries utilizing ICD-10 and AAAM coding systems.
• Each registrar will be current with records. At a minimum 80% of cases must be completed within 60 days of patient discharge.
• Participates in data validation process to ensure the integrity of the collected data. Each registrar is expected to have a 95%, or better, accuracy rate per the Data Validation form established within the Trauma Registry.
• Actively participates in updating data dictionary or other reference documents that facilitate increased productivity and accuracy.
• Collaborates with the Trauma Program Manager in maximizing the efficiency of abstracting the required data elements from the medical record and other available sources by reporting critical gaps in the medical record documentation.
• Actively participates in ongoing preparation for the American College of Surgeons (ACS) site visit.
• Collaborates in a professional manner with all members of the healthcare team to promote the goals and objectives of the Division of Trauma.
• Participates in professional development/educational activities to ensure advancement of skills and knowledge of trauma care and data information systems.
• Complies with all institutional and departmental policies, procedures and objectives.
• Other duties as assigned by the Trauma Program Manager.

MINIMUM QUALIFICATIONS:

EDUCATION/CERTIFICATIONS:

• High School graduate or equivalent required. Associate's or bachelor's degree in Medical Record Management or related health science field preferred.
• Completion of Trauma Registrar course within 9 months of hire
• Certification in Injury Severity Index Scoring/AIS within 1 year of employment.
• CCA or CCS certified highly desirable.

EXPERIENCE, KNOWLEDGE, SKILLS:

• Solid knowledge of anatomy required.
• Strong medical terminology background required with at least 2 years of healthcare experience.
• Solid knowledge of ICD-10- CM preferred.
• Knowledge of database management and Microsoft Office Suite required.
• Ability to represent the organization and serve consumers in a professional manner and promote a positive image of the organization.
• Work requires high degree of initiative, judgment, discretion, and ability to function independently.
• Must be detailed oriented and possess strong organizational skills.

SUPERVISORY RESPONSIBILITY

None.

Pay Range:

$24.29-$40.07

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location:

Corporate Headquarters - 15 LaSalle Square Providence, Rhode Island 02903

Work Type:

M-F 8:00am-5:00pm

Work Shift:

Day

Daily Hours:

8 hours

Driving Required:

No