Trauma Registrar - Rotating

About the position

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, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. The Trauma/Surgery Registrar assigns ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities and complications according to methodologies and coding rules. This position performs on-going daily chart reviews on all patients and enters data into the Registry. The Trauma/Surgery Registrar reports complications and quality issues to the Supervisor. The Trauma/Surgery Registrar ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies. The Trauma/Surgery Registrar assists with performance improvement activities.

Responsibilities

• Maintain a registry database for Trauma and Surgical Programs.
• Identify cases for inclusion into the registry database.
• Abstract data from various sources including electronic medical records and prehospital databases.
• Assign ICD-10 diagnosis codes and other specialized coding.
• Perform daily chart reviews on all patients.
• Enter data into the Registry.
• Report complications and quality issues to the Supervisor.
• Ensure adherence to data management protocols.
• Assist with performance improvement activities.

Requirements

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification or Registered Health Information Technician (RHIT) preferred.
• 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.
• 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.

Nice-to-haves

• Experience in trauma or surgery registry abstraction/coding depending on job assignment.
• Expert skills using Windows-based software (word processing, spreadsheet, databases).
• Abstracting experience using current requirements by state and national regulatory bodies.
• Experience 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 standards of data quality control.
• Completion of ICD-10 coding courses.