Trauma Registrar - Rotating

Overview

The Trauma/Surgery Registrar supports the VCU Health System’s adult or pediatric Trauma and Surgical Programs and organizational requirements for verification as Level 1 Trauma/Surgery Center by the Commonwealth of Virginia and the American College of Surgeons by maintaining a registry database. This includes identification of cases for inclusion into the registry database and abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources.

• Assign ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury Scale Scores) to procedures, comorbidities, and complications according to methodologies and coding rules.
• Perform ongoing daily chart reviews on all patients and enter data into the Registry.
• Identify and abstract data from multiple sources and ensure accurate and timely reporting of data to the organization and regulatory agencies.
• Report complications and quality issues to the Supervisor and assist with performance improvement activities.

• Certified Professional Coder (CPC);
  Certified Coding Specialist (CCS); or equivalent coding certification; or Registered Health Information Technician (RHIT) preferred.
• Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 18 months of hire is required for Trauma Registrars; or CPC/CSS or other equivalent coding certification within 18 months of hire for Surgery Registrars.

• Required:
  
  One (1) year work experience in registry data abstraction/coding, or two (2) years of experience in medical data abstraction/coding.
• Proficiency with MS Office software including email, MS Word, and MS Excel.
• Preferred:
  Experience in trauma or surgery registry abstraction/coding depending on job assignment; expert skills using Windows-based software (word processing, spreadsheet, databases); abstracting experience with current state and national regulatory requirements; familiarity with medical terminology and acronyms related to diagnosis, procedures, complications, and comorbid conditions; experience with accurate and timely data entry and verification to maintain high data quality standards.

• Required:
  
  Associate’s Degree in any field that includes two semesters of medical terminology and Anatomy/Physiology, or in medical records coding from an accredited program. Work experience may be considered in lieu of credentials where allowed by HR; role-specific experience required.
• Preferred:
  Completion of ICD-10 coding courses.

Performs daily chart reviews on specific patients. Assigns ICD-10 and other specialized codes and enters data into the registry. Interprets medical information. The Registrar is assigned patients of basic to moderate complexity, including patients with multiple complications, including deaths.

Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys. Age Specific groups served: N/A

Physical lifting less than 20 lbs. Prolonged sitting, keyboarding, mouse; strong recall, reasoning, problem solving, hearing, clear speech, legible writing, reading, logical thinking. Emotional: fast pace environment, steady pace, able to adapt to frequent change. Rotating

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