Trauma Registrar Associate

Atrium Health; Macon (GA); On-site; USD 42,000 - 66,000; Full time

Job summary

Atrium Health in Macon, GA is seeking an AIS coding professional to analyze and abstract patient injury data and assign AIS/ICD-10 codes per current guidelines. You will apply NTDS and Georgia definitions, identify events and comorbidities, and ensure data accuracy.

The role emphasizes confidentiality, continuous education, and participation in quality improvement activities within trauma registry processes.

Qualifications

• Comprehensive knowledge of anatomy and medical terminology and procedures.
• Excellent communication skills and ability to accurately type 30 WPM.
• Experience with EHR (electronic medical record) use required.

Responsibilities

• Analyze and abstract patient injury diagnoses and treatment information and accurately assign injury diagnoses and procedure codes.
• Appropriately apply NTDS, Georgia DPH and facility data definitions and guidelines.
• Identify events, complications, and comorbidities per NTDS definitions.
• Identify facility trauma population per NTDS, Georgia and registry criteria.
• Maintain accuracy rate greater than 95% and confidentiality of trauma data.
• Assist with Trauma Services preparation and hospital surveys.
• Participate in quality and process improvement for data accuracy.
• Attend Registry and other meetings; maintain ongoing education records.
• Support data validation projects and inter-rater reliability peer validations.

Skills

Anatomy knowledge

Medical terminology

Excellent communication

Typing 30 WPM

EHR experience

Education

High school diploma or GED

Associate degree preferred

Tools

Epic EHR

ESO/V5 trauma DB

Microsoft Word

Outlook

OneNote

Teams

Excel

Job description

• Analyze and abstract patient injury diagnoses and treatment information from multiple sources and accurately assign injury diagnoses and procedure codes in accordance with current AIS and ICD-10 guidelines.
• Appropriately apply the current National Trauma Data Standard (NTDS), Georgia DPH and facility data definitions and guidelines.
• Identify hospital events, complications, and comorbidities in accordance with National Trauma Data Standard (NTDS) definitions.
• Identification of facility’s trauma population in accordance with NTDS, Georgia, and facility registry inclusion criteria.
• Consistently meet agreed upon goals for record completion while maintaining an accuracy rate greater than 95%.
• Ensure and maintain reliability and confidentiality of trauma patient data.
• Be familiar with the Registry chapter requirements from the current version of the American College of Surgeons, Optimal Resource for Care of the Injured Patient.
• As assigned, assists with preparation for Trauma Services and hospital surveys.
• As assigned, participates in quality and process improvement activities to ensure the accuracy of data collection.
• Attends hospital Registry and other meetings as assigned.
• Maintains compliance with departmental and TQIP/ACS sanctioned ongoing education and maintains records of personal education. Identifies training/learning needs and seeks out educational opportunities.
• Supports data validation projects and inter-rater reliability peer validations.
• Meets productivity goals and strives to meet stretch goals as assigned.
• Ability to comprehend and operate various computer programs.

Major Responsibilities

• Analyze and abstract patient injury diagnoses and treatment information from multiple sources and accurately assign injury diagnoses and procedure codes in accordance with current AIS and ICD-10 guidelines.
• Appropriately apply the current National Trauma Data Standard (NTDS), Georgia DPH and facility data definitions and guidelines.
• Identify hospital events, complications, and comorbidities in accordance with National Trauma Data Standard (NTDS) definitions.
• Identification of facility’s trauma population in accordance with NTDS, Georgia, and facility registry inclusion criteria.
• Consistently meet agreed upon goals for record completion while maintaining an accuracy rate greater than 95%.
• Ensure and maintain reliability and confidentiality of trauma patient data.
• Be familiar with the Registry chapter requirements from the current version of the American College of Surgeons, Optimal Resource for Care of the Injured Patient.
• As assigned, assists with preparation for Trauma Services and hospital surveys.
• As assigned, participates in quality and process improvement activities to ensure the accuracy of data collection.
• Attends hospital Registry and other meetings as assigned.
• Maintains compliance with departmental and TQIP/ACS sanctioned ongoing education and maintains records of personal education. Identifies training/learning needs and seeks out educational opportunities.
• Supports data validation projects and inter-rater reliability peer validations.
• Meets productivity goals and strives to meet stretch goals as assigned.
• Ability to comprehend and operate various computer programs.

Licensure, Registration, and/or Certification Required

• AAAM AIS Coding course and ATS trauma registry course within one (1) year of hire.
• Certified Abbreviated Injury Scaling Specialist (CAISS) certification required within two (2) years of hire.

Education Required

• High school diploma or GED required.

Experience Required

• One year of experience working in a hospital or physician practice.

Knowledge, Skills & Abilities Required

• Comprehensive knowledge of anatomy and medical terminology and procedures is required as demonstrated through work experience and/or education.
• Excellent communication skills and ability to accurately type 30 WPM.
• Experience with EHR (electronic medical record) use required.

Physical Requirements and Working Conditions

• Must be able to sit for prolonged periods of time.
• Must be able to lift and carry multiple heavy coding books and manuals, up to 10 pounds.
• Must have close visual acuity to perform activities such as: viewing electronic database and Electronic Medical Record (EMR) documentation; extensive reading of electronic and hard copy references; reviewing and analyzing data and figures.

Preferred Education

• Associate’s degree in a health-related field preferred.

Preferred Licensure, Registration, And/or Certification

• RHIT, RHIA, CPC, CCS, CCA certification preferred.

Preferred Experience

• One year ICD-10-CM & ICD-10-PCS coding experience strongly preferred.
• Trauma/Injury registry experience preferred.

Preferred Knowledge, Skills & Abilities

• Epic EHR experience and proficiency in using Microsoft Suite, including Word, OneNote, Outlook, and Teams Video Conferencing software preferred.
• ESO/V5 trauma database software experience preferred.

All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.

This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position. Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders.