Trauma Registrar (Fulltime)

Penn Medicine, University of Pennsylvania Health System; Lancaster (Lancaster County); On-site; USD 52,000 - 78,000; Full time

Job summary

Penn Medicine at Lancaster General Hospital is seeking a Trauma Registrar to manage and audit trauma patient records, ensure accurate coding, and support data reporting for performance improvement. The role requires data abstraction, coding accuracy, and collaboration with Trauma Services to maintain registry integrity.

Responsibilities include calculating AIS scores, generating reports, and participating in education sessions and trauma-related committees to enhance patient care and data

Qualifications

• HS diploma or equivalent.
• 2+ years experience as an Allied Health professional.
• Working knowledge of ICD-9-CM and PC.
• RHIA/RHIT or RN or allied health certificate/degree preferred.

Responsibilities

• Performs concurrent in-house trauma record abstraction and entry into the trauma database in a timely manner.
• Assigns ICD-9-CM codes for injury descriptors and procedures; determines AIS scores.
• Analyzes data and provides information to support Trauma Service improvement initiatives.
• Acts as system administrator for the Trauma Registry and maintains data integrity.
• Identifies patients for registry inclusion and submits data to the PA Trauma Systems Foundation.
• Generates reports and graphics for Trauma Administration and committees.

Skills

Data abstraction

ICD-9-CM coding

Data analysis

Report writing

Trauma registry systems

Education

High School diploma

RHIA/RHIT or RN preferred

Tools

Tricode software

AIS scoring

ICD-9-CM coding books

Trauma registry encoder

Job description

Description
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Description
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?
Location: Lancaster General Hospital; PA Residents
Schedule: Fulltime/40 Hours Per Week/ 10- Hour Workday; 6:00am-4:00pm; No weekends or holidays
(In-person for the 1st year of employment)
Requirements: Medical Terminology Experience
POSITION SUMMARY: Responsible for complete and accurate review of all trauma patient records, collecting data for the PA Trauma Systems Foundation (PTSF), trauma services medical record abstract, and decision support in managing the care of the trauma patient. Maintains and protects the integrity of the Trauma Registry database including S.M.S. and Collectorä interfaces, data management, data analysis, report writing, as well as statistical and graphic output of trauma data.
ESSENTIAL FUNCTIONS:

• Performs concurrent in-house trauma record abstraction and interprets the clinical data in the record for accurate entry into the trauma database in a timely manner. Generates and analyzes concurrent data reports in response to Trauma Service requests or through self-directed processes. Maintains confidentiality and security of all patient data in the Trauma Registry.
• Accurately assigns applicable ICD-9-CM codes for all injury descriptors and procedures found in the trauma patient medical record. Determines optimal AIS score for injuries. Effective utilization of the ICD-9-CM coding books, Tricodeä software, Abbreviated Injury_Scale scoring book by the Association for the Advancement of Automotive Medicine, and encoder are essential. Conforms to PTSF requirements for Accredited Trauma Center participation in the state registry.
• Actively participates as a vital team member in concurrent and retrospective Trauma Service performance improvement initiatives by providing expertise with data retrieval and data manipulation from the trauma registry system. Analyzes data and provides information ensuring that customer requirements are met by utilizing reports and graphics.
• Acts as system administrator for the Trauma Registry. Assures the integrity of the system with timely updates, enhancements, and system back-up. Is able to independently troubleshoot hardware and software system problems as they arise.
• Concurrently analyzes patient medical records according to established criteria to identify patients for inclusion in the Trauma Registry database. Accurately and efficiently identifies PTSF qualifiers and audit filters and assures timely submission of data via the electronic bulletin board system to the PA Trauma Systems Foundation. Maintains an accurate trauma patient log.
• Functions as an important resource to plan, identify, trend, analyze, and integrate new data collection elements for use in trauma patient care management, performance improvement, statistical and research purposes. Proficient in report writing skills while utilizing trauma registry data.
• Attends and actively participates in required PTSF and hospital education sessions. Participates on trauma-related committees. Demonstrates communication skills that support the registrar’s role in trauma initiatives.
• Participates in registrar inter-rater reliability reviews.
• Completes a statistical report of all trauma patient and registry data and prepares a monthly report to Trauma Administration.
• Prepares pull lists for special studies and audits.
• Assists and actively participates in site survey process.
• Assists in research projects in tandem with the Trauma Services team.

MINIMUM REQUIRED QUALIFICATIONS:

• Req H.S. Diploma/GED High School diploma or equivalent.
• Req 2+ years Two (2) years experience as an Allied Health professional is essential.
• Req Working knowledge of ICD-9-CM and personal computer is essential.
• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT) or Registered Nurse (RN) or completion of certificate/degree in Allied Health profession is preferred.

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work
We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.