Collects, abstracts, analyzes, and reports on data collected from trauma patient medical records.
• Identifies and analyzes the history, diagnosis, treatment, prognosis, and survival data of trauma patients treated in the organization.
• Analyzes trauma-related documentation/charting for compliance with applicable quality assurance standards, including those of the American College of Surgeons and the State of Florida Office of Trauma.
• Assists the Trauma Program staff with developing criteria for patient care evaluation, collecting data for mandatory registry and protocol studies, and conducting audits.
• Complies with all reporting requests and requirements.
Competencies and skills:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.
• ACCURACY: Completes work assignments within established quality and/or quantity standards.
• ANALYSIS AND DECISION MAKING: Uses decision making processes and tools to analyze situations and make effective decisions.
• EFFECTIVE COMMUNICATION: Communicates effectively with various audiences using the most appropriate method for the situation.
• TEAM WORK: Contributes to fullest potential to achieve team goals.
• ORGANIZATION SKILLS: Organizes work to achieve maximum efficiency.
• PATIENT AND FAMILY CENTERED CARE: “Provides Patient and Family Centered Care to patients, families, visitors and internal customers”
• HIPAA: Complies with the Health Insurance Portability and Accountability Act.
• JOINT COMMISSION: Facilitates and/or ensures compliance with The Joint Commission’s (TJC) accreditation process and requirements.
• HEALTH INFORMATION MANAGEMENT: Maintains patient information within current legal requirements and privacy laws.
• MEDICAL CODING: Transforms verbal descriptions of diseases and procedures into numeric designations.
Education equivalent experience:
• Associate’s degree in health-related field or equivalent work experience of at least 2 years
Complexity of Work: Must have: knowledge of medical terminology, anatomy and physiology, and/or coding knowledge; proficiency in utilizing computers; trauma experience; AIS/ISS, ICD-10 coding familiarity. Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.
Required Work Experience: 2 years