Certified Trauma Registrar - Pool

Minimum Qualifications:

• High school diploma or equivalent required.
• Must attend (1) the American Trauma Society's Trauma Registrar Course or equivalent; (2) the Association of the Advancement of Automotive Medicine's Injury Scaling Course (AAAM AIS) within 12 months or first available class; (3) ICD-10 course (dated within the past 5 years).
• Certified Abbreviated Injury Scale Specialist (CAISS) required within 2 years from date of hire.
• Data entry experience with focus in databases required.
• Proficiency in Microsoft Office skills required.

POSITION SUMMARY

Trauma Registrar Role:
The trauma registrar, utilizing critical thinking, is responsible for the collection, entry, maintenance and reporting of data for the appropriate regulatory agencies. Utilizing analytical and cognitive skills, the registrar shall utilize the collected data for research, epidemiology, prevention initiatives and performance improvement. The data shall be obtained from the paper and electronic medical records. The registrar will code and enter data into the computerized registry, maintaining confidentiality at all times. It is important to acknowledge that high-quality data begins with high-quality data entry, and it is the registrar who is responsible for performing this task.

The trauma registrar performs complex technical analyses of patient data. This position assumes direct responsibility for accuracy, completeness, confidentiality and data entry of information collected in compliance with the American College of Surgeons and the State of New Jersey. The registrar analyzes and interprets all available patient data to determine extensive coding classifications, including ICD-10 diagnosis and procedure coding, E-codes (External Causes of Injuries) and AAAM (Association for the Advancement of Automotive Medicine) learning course for AIS (Abbreviated Injury Scale) 2005 (Update 2008). The AIS system describes the severity of injuries throughout the body, which assigns and scores all injuries.

The registrar evaluates the documentation of nursing staff/hospital providers and identifies missing data elements. Coordinates with trauma program manager/director and/or nursing to correct and obtain information for hospital records.

The registrar is directly responsible for providing community follow-up and ensuring completion of the medical record. Proficient in running quality and data reports from the registry module in various capacities. Performs other assigned duties as designated by the program manager and/or director.

The registrar also maintains participation in trauma center activities and national, regional or state programs. This position also participates in injury prevention, outreach and education done by the Trauma Center. The registrar is an active member of the Performance Improvement and Patient Safety Program and helps to ensure continuous quality improvement, which will ultimately enhance patient safety and associated excellence in outcomes.

Trauma Report Writer Role:
The trauma report writer has additional responsibility for creating, generating and validating institutional-specific trauma data, including, but not limited to, quarterly scorecards, trauma committee statistics, Cribari over and under triage, trauma helicopter reports, weekly trauma arrival reports for billing and HIM validation, custom-built clinical data requests, media-related reports, follow-up letters for outside organizations and EMS follow-up, patient outreach data, performance improvement reports and provider compliance reports.

The report writer is also the lead responsible for generating and validating national data for the American College of Surgeons PRQ report required for trauma center accreditation.

QUALIFICATIONS

• EDUCATION: High school diploma or equivalent required. One or more years of college with courses in medical terminology, anatomy and physiology preferred. ICD-10-CM coding, AIS 2005 coding with 2008 update preferred.
• LICENSE/CERTIFICATION: Certified Abbreviated Injury Scale Specialist (CAISS) required within 2 years from hire date.
• EXPERIENCE: Experience with exposure to patient management is preferred. Proficiency with Microsoft Office applications, specifically Word and Excel. Data entry experience with a focus in databases is desirable. Computer skills required. Proficiency in clinical applications preferred at time of hire. Incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

PERFORMANCE EXPECTATIONS
Demonstrates the competencies as established on the Assessment and Evaluation Tool for this position.

WORK ENVIRONMENT
Potential for exposure to the hazards and risk of the hospital environment, including exposure to infectious disease, hazardous substances and potential injury. This position requires sitting, standing, walking, stooping and crouching a majority of the workday. Works with such equipment as a computer terminal, fax machine, printer and copier.

REPORTING RELATIONSHIP
This position reports to department leadership.

The above statement reflects the general details considered necessary to describe the principl functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.