Trauma Registrar - Tucson, United States - Banner Health

Description

POSITION SUMMARY

This position participates in activities associated with the trauma registry, including data gathering, data abstraction, timely and accurate data entry/coding, data validation and reporting that meets trauma center requirements. Acts as a member of the multi-disciplinary trauma team to support patient quality and performance improvement initiatives.

CORE FUNCTIONS
1. Collects required information for all injured trauma victims meeting inclusion criteria by reviewing multiple sources including medical records, EMS records, and various hospital software programs. Abstracts required data elements including basic patient demographics, clinical procedures, clinical and diagnostic results, etc. Enters data accurately related to the trauma patient's history, diagnosis, therapy, and outcome.

2. Uses scaling and scoring tools such as current International Classification of Diseases codes (ICD), the Abbreviated Injury Scale (AIS) developed by the Association for the Advancement of Automotive Medicine (AAAM), and Injury Severity Score (ISS).Codes injuries and procedures for the database as required for clinical care, research, benchmarking and accreditation. Ensures the hospital remains compliant with all applicable standards as they relate the respective State registry, American College of Surgeons, National Trauma Data Bank, Trauma Quality Improvement Program (TQIP) and trauma center accreditation.

3. Maintains the Trauma Registry database in compliance with state regulations and accreditation requirements. Assists team with documentation and management of the registry database as it relates to clinical research, benchmarking and accreditation.

4. Develops and produces timely information/reports as requested and contributes to timely data submission to national and state agencies to ensure accreditation/verification/designation statuses are maintained.

5. Works as an integral part of the trauma quality and performance improvement program by contributing to identification of opportunities for improvement and/or areas of concern commensurate with the level of training/knowledge/experience.

6. Works independently under limited supervision. This position functions at assigned facility and has no budgetary responsibilities. Internal and external customers include physicians, clinical staff, facility employees, trauma team members and state and national agencies.

MINIMUM QUALIFICATIONS

Requires a level of education equivalent to that of a Registered Health Information Technologist (RHIT) or certified coder, including advanced education in medical terminology, anatomy and physiology.

Must have or will have required course work, including the ATS trauma registrar course, AIS training course, within one year of hire.

Must have a level of experience and ability in coding, abstracting and data management as normally acquired over two or more years of clinical and/or experience in a coding or clinical data management position. Requires the ability to interpret and comprehend information contained within the patient's medical record and to find all required data elements for the Trauma Registry. Requires the ability to abstract registry data from the patient's medical/health record using the above standard setters regarding abstracting and coding procedures.

Must have excellent organizational, written and verbal communication skills, and the ability to prioritize multiple work projects and tasks.

Exceptional data entry and data management skill sets are required with an expected high degree of accuracy. Must be able to work effectively with common office computer software, the Trauma Registry software, the electronic medical records system and databases, spreadsheet and graphical programs.

PREFERRED QUALIFICATIONS

Registered Health Information Technologist or Registered Health Information Administrator certification (RHIT or RHIA), Certified Professional Coder (CPC), Certified Specialist Trauma Registry (CSTR) preferred.

Past trauma registry experience preferred.

Additional related education and/or experience preferred.

EOE/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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