Primary Function/General Purpose of Position

The Trauma Registrar is responsible for the collection and abstraction of data base elements following the criteria of inclusion for state and/or national trauma databases. The Trauma Registrar, reporting directly to the Trauma Program Manager, supports the organizational requirements for by the State of Ohio and the standards set forth by the American College of Surgeons for maintaining a trauma registry database. Assigns diagnosis and procedure codes for the purpose of research and compliance with state and federal regulations.

Essential Job Functions

• ​The Trauma Registrar identifies cases for inclusion into the registry data base

• Data abstracted will be from various sources including, but not limited, to the electronic medical record, prehospital databases, autopsies reports, and other data sources, either electronic or not that will substantiate the injured patient

• The Trauma Registrar will assign ICD-10 CM diagnosis codes and ICD-PCS procedure codes according to the established and published Official Coding Guidelines. 

• The Trauma Registrar will assign and verify AIS codes required for severity of illness and probability of survival as established through AAAM manual for AIS coding

• Daily chart review and data entry into the Trauma Registry on established patients who meet criteria will be performed.

• The Trauma 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 Registrar assists with performance improvement activities.

Licensing/Certification

REQUIRED (One or More):

• Registered Health Information Technician (RHIT)

• Registered Health Information Administrator (RHIA)

• Certified Professional Coder (CPC);

• Certified Coding Specialist (CCS);

• Or other equivalent education and experience

• Must complete and pass AIS Coding by AAAM within 12 months of hire (Required)

• Must complete and pass ICD-10 Trauma specific coding course within 12 months of hire (Required)

• Ongoing data validation scores at the level of 90% accuracy following 12 months of employment and fulfillment of onboarding training requirements. (All levels registrars must maintain- Required)

Education

• Completion of ICD-10 coding courses (Required)

• Completion of college-level Anatomy/Physiology courses (Required)

• Completion of college-level Medical Terminology courses (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. (Preferred)

Work Experience

• Minimum of one (1) year experience working directly with medical records and computer

• One (1) – Two (2) year work experience in registry data abstraction/coding

Training

• Current knowledge of ICD-10-CM and ICD-10-PCS coding principals

• Proficiency with MS Office software including email, MS-Word, and MS-Excel. Expert skills with word processing, spreadsheets, and databases.

Skills

• 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

• ​Performing daily chart reviews on specific patients.

• Assigns ICD-10 and other specialized codes and enters data into the registry.

• Interprets medical information.

• Attention to detail

• Critical thinking

• Conflict resolution

• Active listening

• Relationship building

• Ability to function independently and as part of a team and thrive in a fast-paced environment.

• Ability to work additional hours if the work warrants it.