Pediatric Trauma Registrar, Brenner's Children's Hospital

Pediatric Trauma Registrar, Brenner's Children's Hospital

40 hour per week, day shift

JOB SUMMARY:  

The Pediatric Trauma Registrar is responsible for the identification, collection, abstraction, and data entry of required state and national trauma data bank elements into the Trauma Registry database on all patients meeting state and national trauma inclusion criteria. This includes coding diagnoses, procedures, and injuries utilizing ICD-10 coding, AIS coding, E-codes, and entering data into the Trauma Registry per National Standards and State Trauma regulations published by the American College of Surgeons (ACS). The Trauma Registrar maintains the confidentiality of the registry data and provides registry data as appropriate for research. The Trauma Registrar interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions. The Trauma Registrar is responsible for keeping the registry current according to the standards of the American College of Surgeons.

EDUCATION/EXPERIENCE: 

A minimum of a High School diploma or GED and 2 years of experience in medical record coding or relevant clinical experience preferred.  Pediatric trauma registry experience preferred

LICENSURE, CERTIFICATION, and/or REGISTRATION:  

CSTR (Certified Specialist in Trauma Registry) required within 18 months of hire. AAAM course certification (AIS coding) and Trauma Registry Course required within 1 year of hire.   CAISS required within 18 months of hire.  RHIT, RHIA, CCS, preferred.

ESSENTIAL FUNCTIONS:

1. Performs data collection of demographics and coding of clinical and follow-up data from all sources into trauma registry database.
2. Interacts with physicians, nurses, and other members of the trauma team and trauma patients and families to perform trauma registry functions.
3. Keeps registry current at least as defined by the ACS as 80% complete within 60 days of patient discharge.
4. Patient entry into the Trauma Registry determined based on guidelines in the ACS “Resources for the Optimal Care of the Injured Patient” in addition to the National Trauma Data Standard.
5. Provides high-quality data entry by abstraction of required state and national trauma data elements from the patient chart in real-time and retrospectively.
6. Participates in benchmark reporting (such as TQIP), quality assurance, data validation, and improvement activities to ensure accuracy of data collection and timely submission of data according to State Trauma Registry and the ACS Optimal Resource Document for Trauma Centers.
7. Completes in Inter-rater reliability (IRR) validation with a minimum score of 90%, optimal score of > 95%.
8. Participates in performance improvement monitoring by gathering data on performance metrics, identifying, and reporting complications, and performing analysis of registry data in support of clinical process improvement initiatives. Prepares reports pertinent to Trauma performance improvement and reports issues and trends identified to PI Coordinator and TPM.
9. Drafts reports from the Trauma Registry Database for information requests by trauma administration, physicians, and other approved entities to support coding, billing, trauma research, injury prevention, performance improvement, Trauma Center Designation/Verification process, and other activities of the Trauma Program. Ensures compliance with Atrium Health Wake Forest Baptist HIPPA and IRB research policies.
10. Attends and participates in Multi-disciplinary Trauma Patient Rounds, Multi-disciplinary Trauma Committee, other trauma forums as determined by the TPM, and the NC State Registrar Sub-Committee. 
11. Maintains ICD-10, AIS, and TQIP coding updates.
12. Maintains required continuing education as mandated by the ACS standards. 

SKILLS/QUALIFICATIONS:

• Knowledge of ICD-10 coding (injury coding), AIS coding, E-codes, anatomy, physiology, medical terminology, and disease processes. 
• Must be proficient in keyboarding, spreadsheets, word processing, and databases. 
• Requires ability to analyze and report registry data to support the activities of the Trauma Program. 
• Must have ability to work independently and have a strong aptitude for detail.

WORK ENVIRONMENT:

• Subject to varying and unpredictable situations
• Occasional pressure due to multiple calls and inquiries 
• Subject to many interruptions
• Occasionally subject to irregular hours
• Travel required