Senior Trauma Registrar

This job supports the VCU Health Trauma Program and organizational requirements for verification as a Level 1 Trauma Center by the Commonwealth of Virginia and the American College of Surgeons Committee on Trauma by maintaining a unique database called the Trauma Registry. This includes identification of cases for inclusion into the trauma registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. This job assigns ICD 10 diagnosis codes and Abbreviated Injury (AIS) Scores to injuries, procedures, comorbidities and complications according to ICD-10 and Abbreviate Injury Scoring methodologies and coding rules. This job performs on-going daily chart reviews on all injured patients and enters data into the Trauma Registry. This job reports complications and quality issues to the Trauma Registry Operations Coordinator or Trauma Program Manager. This job ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the Organization and regulatory agencies. This job also assists with performance improvement activities and information requests.

Licensure, Certification, or Registration Requirements for Hire: Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS) or Certified Specialist in Trauma Registry (CSTR)

Licensure, Certification, or Registration Requirements for continued employment: Certified Specialist in Trauma Registry (CSTR) must be obtained within 6 months of hire Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS)

Experience REQUIRED:

Three (3) years of work experience in trauma registries or five (5) years experience in medical data abstraction/coding

Abstracting experience using current requirements by state and national regulatory bodies

Expert proficiency with Windows-based and MS Office software including email, MS-Word, and MS-Excel and databases

Experience PREFERRED:

One year of experience in trauma registry abstraction in an academic medical center Expert at ICD-10, Abbreviated Injury and Injury Severity Scoring

Experience analyzing requests for data and creating moderate to complex reports from the registry

Excellent investigative/analytical skills with detail orientation

Understanding of medical terminology and acronyms related to accurate identification and coding of injuries and procedures

Experience analyzing data for accuracy and validating data for submission to national databases in a timely manner

Familiarity with information technology hardware and software in a local and wide area network environment

Education/training REQUIRED:  

(Note: work experience may be considered in lieu of credentials not required by law with HR approval. Work experience must be specific to role)

Associates Degree in a healthcare-related field or in medical records coding including at least two semesters of human anatomy/physiology and medical terminology from an accredited program

Education/training PREFERRED: Completion of ICD-10 coding courses

Additional position requirements:

Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.

Physical Requirements (includes use of assistance devices as appropriate):

Physical: Lifting less than 20 lbs.

Activities: Prolonged sitting

Repetitive motion: Keyboarding, Mouse

Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking

Emotional: Steady pace, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change

Essential Function

Performance Expectations: Abstraction/Coding 
Identifies reportable injuries. Reviews and abstracts information from patient medical records (VCUHS, prehospital, outside agencies) including demographic characteristics, history of injury, diagnostic procedures, final diagnosis, comorbidities, treatments, complications and outcomes. Independently researches and solves highly complex coding problems. Accurately code injuries to ICD-10 and Abbreviated Injury Scoring and enter into database (trauma registry). Maintains minimum 95% accuracy rate per abstract. An accurate abstract is defined as a patient registry file/abstract with no errors. Maintains a concurrent process of data abstraction and coding. Concurrent is defined as at least 90% of assigned cases are opened within 48 hours of assignment and at least 50% of assigned cases are closed within 2 weeks of discharge and 75% are closed within 30 days of discharge. Abstracts other requi