Trauma Registrar - Rotating

Trauma/Surgery Registrar

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.

Licensure, Certification, or Registration Requirements for Hire: Certified Professional Coder (CPC); Certified Coding Specialist (CCS); or equivalent coding certification or Registered Health Information Technician (RHIT) preferred Licensure, Certification, or Registration Requirements for continued employment: 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 Certified Professional Coder (CPC), Certified Coding Specialist (CSS), or other equivalent coding certification within 18 months of hire is required for Surgery Registrars

Experience 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 Experience 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 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

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

Independent action(s) required: 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. Supervisory responsibilities (if applicable): N/A

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. Age Specific groups served: N/A 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: Fast pace environment, Steady pace, Able to adapt to frequent change

This position is a day/evening shift position and remote work is possible