Trauma Registrar- Full-Time Day Shift- Hybrid

Wellstar Health Systems; Roswell (GA); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Wellstar Health Systems in Roswell, GA, is seeking a Trauma Registrar for a full-time, day-shift role with hybrid flexibility. You will manage the trauma registry, perform data abstraction, validation, and reporting to ensure accurate benchmarks and compliance with NTDB/TQIP standards.

Responsibilities include coding using ICD-10-CM/PCS and AIS, data entry from EHR sources, and collaboration with the Trauma Program Manager to drive quality improvement across Level II/III centers and burn/trauma

Qualifications

• Must possess strong data management and attention to detail.
• Familiarity with health information systems preferred.

Responsibilities

• Abstract data from electronic health records to complete trauma records within hospital Trauma Registry.
• Assign ICD-10-CM/PCS and AIS codes to trauma data entries.
• Validate data quality, perform regular audits, and generate reports for NTDB/TQIP benchmarks.

Job description

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work ShiftDay (United States of America)

Job Summary:

Trauma Registrar- Full-Time Day Shift- Hybrid

The Trauma Registry is a complex injury and disease specific database that is integral to the operations of the trauma center. Quality Trauma Registry data must be collected by every trauma center and is critical to the success of a trauma program. The Trauma Registrar is responsible for the management of all components of the Trauma Registry, including data collection, data abstraction, data entry, data retrieval/statistical conversion, and data validation.

The Trauma Registrar Position reports directly to Trauma Program Manager.

Key responsibilities of the role include:

• Data abstraction/entry, database management, inter-rater reliability and data validation, uploading data to state and national Trauma Registries, analysis of data frequency submission reports, monitoring the data base for data integrity and mapping inconsistencies as well as error correction and report writing.

Level I and II Trauma Centers:

Trauma Registrars at Level I and II trauma centers are responsible for coding extensive injury complexes, procedures, complications, and prolonged hospitalizations. They are also responsible for coding additional data elements for the Trauma Quality Improvement Program (TQIP) and participate in required Georgia Quality Improvement Program (GQIP) state drill down exercises. The Trauma Registrar is an integral member of the Performance Improvement process within the Level I and II trauma center and assist with data re-review upon TQIP Benchmark report receipt biannually.

Level III and IV Trauma Centers:

Trauma Registrars at Level III and IV trauma centers are not responsible for coding additional data elements for TQIP (unless the Level III center is a participating TQIP facility). Patients with extensive injury complexes receive initial stabilization and are typically transferred out to Level I or II trauma centers when resources at these facilities are exceeded. The admitted, non-transferred out, patient population at the Level III and IV trauma centers usually have minimal procedures, lessened injury complexes, and shorter length of stays for coding.

Burn Centers:

Burn/Trauma Registrars are responsible for coding data elements in both the burn and trauma registries. The burn registry requires less data entry elements than the trauma registry, however, patients within this registry tend to have complex coding requirements secondary to necessitating multiple procedures and prolonged hospitalizations.

Trauma Registry data is vital to daily operations, process improvement, benchmarking and improving the quality of trauma care delivery. Injury Prevention and Outreach events are developed based on the trauma population captured within the Trauma Registries. Ongoing trauma operations including staffing for trauma clinical care units and Trauma Surgery staff is based on trauma volume and trends.

There are regulatory and statutory requirements for Trauma Centers to maintain high quality Trauma Registries. Trauma Registrars must maintain proficiency in anatomy/physiology, in health information technology, trauma specific software, and knowledge of a variety of trauma scoring/scaling methods is essential. The Trauma Registrar must also have knowledge of two independent coding systems: ICD-10-CM/PCS and Injury Severity Coding (AIS). The Trauma Registrar must also learn EMS procedures and terminology, nursing procedures and terminology, radiology terminology, and understand disease processes for capturing comorbid conditions and complications for the registry. They should also have knowledge of ICD-9-CM/PCS for reports and historical data.

Core Responsibilities and Essential Functions:

• a. Responsible for the abstraction of data from various data sources (electronic health record,Trauma Activation Logs, PI Data sheets, etc.) necessary to complete trauma records withinthe hospitals' Trauma Registry.
• b. Utilizes technical coding principles expertise to assign appropriate ICD-10CM diagnosesand ICD-IOPCS procedure codes into trauma database.
• c. Utilizes technical trauma specific coding principles expertise to assign appropriate AIScodes used to calculate the ISS (injury severity score).
• d. Identifies activation levels and report to Charge Capture for appropriate reimbursement.
• e. Identifies records that fall within the Trauma Registry inclusion criteria for hospital, stateand national registries.
• f. Performs data abstraction and entry using established rules and definitions set by theNational Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP), StateRegistry and the hospitals' data dictionaries.
• g. Informs the Trauma Program Manager (TPM) of all relevant trauma audits filterinconsistencies via monthly Quality Assurance Reports.
• h. Informs the Trauma Program Leadership of all opportunities for improvement in traumarelated documentation that may be identified during the data abstraction/entry/validationprocesses.
• i. Meets productivity standards.
• A. Queries physicians when needed to further clarify code assignments.60%

Data Validation and Inter-rater Reliability

• a. Analyzes records for quality assurance trauma standards recommended by the TraumaCommittee and as stipulated by the American College of Surgeons (ACS) and the JointCommission (TJC): Data includes all phases of trauma care, i.e., pre-hospital, emergencydepartment and inpatient
• b. Maintains the highest level of validity to assure accurate program profiling, TQIP, state andinternal data reports using based on defined processes.
• c. Completes routine checks of abstracted data for accuracy and maintains an accuracy rateof 95%.Identifies suspicious or invalid cases, variables and data values, implements correctiveaction for invalid data, and reports findings to the Certified Trauma Data Analyst and TPMfor further review.