This position retrieves, codes, abstracts, and enters clinical and demographic information into the trauma registry database in accordance with current Nevada Administrative Code guidelines. The incumbent is responsible for reporting quality and system issues to the Trauma Coordinator that affect the integrity of the Trauma program.
This position is responsible for obtaining, abstracting, correcting, and entering patient data both concurrently and retrospectively on patients who meet the criteria for trauma as established by the State of Nevada Administrative Code and Renown Regional Medical Center. The incumbent demonstrates ability to analyze and interpret all available patient data to determine appropriate coding classifications for all eligible trauma patients. This position uses ICD-9, ICD-10, and AIS codes.
This position acts as a resource to the Trauma Coordinator, Trauma Medical Director, trauma surgeons, and administration for retrieval of registry data. The incumbent may handle routine requests, generate reports, assist researchers in gathering information for trauma related studies, and provides guidance in the appropriate use of registry data. Complications, audit filters, and physician related issues are among the trends monitored and reported to the Trauma Coordinator and Trauma Medical Director.
In consultation with Trauma Services leadership, the incumbent is responsible for timely chart analysis and completion for submission of data to the State of Nevada, Trauma Quality Improvement Program (TQIP), and to the National Trauma Data bank according to specified criteria and time frames.
Excellent communication skills, the ability to be flexible and function in a fast-changing environment and work under stress along with ability to maintain strict confidentiality is essential. The incumbent must be familiar with HIPPA standards and able to communicate such to physicians, hospital staff, patients and all other customers.
This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications: Requirements – Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English. Must have working knowledge of medical terminology, anatomy and physiology.
Requires 2 years experience in health care, prefer emergency, trauma, or acute care. Working knowledge of ICD-9codes, ICD-10 codes, AIS codes, and pathophysiology preferred.
CSTR (Certified Specialist in Trauma Registries) preferred. CSTR required within 36 months of hire.
Computer / Typing:
Must be familiar with Microsoft Office Suite and be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.