|Under the supervision of the Trauma Program Manager, the Trauma Registrar will abstract relevant data from the EMR to identify the care rendered to the patient for purpose of Level II Trauma Center compliance, research, and trauma quality improvement. The Trauma Registrar will assign ICD-10 injury (E-Code), procedure codes, diagnostic codes, and complication codes in accordance with the NTDB, American College of Surgeons and NCOEMS guidelines. Will be required to work both independently and within a team to maintain productivity standards. This will mainly be a remote role but will be expected to attend staff meetings and training as required ( at least monthly.)|
|Review and abstract quality records to obtain necessary information required by the Hospital System, Providers, ACS, NCOEMS, Joint Commission, and CMS. Confirm completeness and accuracy of data collected/documented by physicians, hospital staff or physician office personnel.|
Understanding of benchmarking reports and meet with quality data owners/customers within the department, hospital system, providers to share data findings and other opportunities for improvement.
Utilize data collection software (Premier, Digital Innovation Registries, and potential other vendors).
Work with CHL team to make improvements in EMR to ensure better documentation and abstraction.
High School Diploma or equivalent.
Completed medical terminology course
Complete ATS Registry Course and AAAM Injury Scaling Course within 12 months of hire
Preferred: Associate degree in medical coding, computer science, or medical informatics.
6 months of experience in the healthcare field and with EMR
Proficient use of computers
1 year preferred of Trauma Registry coding
Valid Driver's License | Valid Driver's License
*If driving Cone Health vehicle, must have 5 years of driving experience and MVR must be approved by Risk Management.
Certified Specialist in Trauma Registry (CSTR)
Certified Coding Specialist (CCS, CCS-P)