VCU Health System's MCV Trauma Program is seeking a Full Time Trauma/Surgery Registrar. Supports the VCU Health System's adult or pediatric Trauma and Surgical Programs and organizational requirements for verification as Level 1 Trauma/Acute Care Surgery Center by the Commonwealth of Virginia and the American College of Surgeons by maintaining a registry database. This includes identification of cases for inclusion into the registry database, abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources. Assigns ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores), procedures, comorbidities and complications according to methodologies and coding rules. Performs on-going daily chart reviews on all patients and enters data into the Registry. Reports complications and quality issues to Supervisor. Ensures adherence to data management protocols set forth to ensure accurate and timely reporting of data to the organization and regulatory agencies. Assists with performance improvement activities.
Performs daily chart reviews on specific patients.
Assigns ICD-10 and other specialized codes and enters data into the registry.
Interprets medical information.
The Registrar is assigned patients of basic to moderate complexity including patients with multiple complications, including deaths.
One (1) year work experience in trauma registry data abstraction/coding, or two (2) years of experience in medical data abstraction/coding.
Proficiency with MS Office software including email, MS-Word, and MS-Excel.
Associates degree in any field that includes two semesters of Medical terminology and Anatomy/Physiology, or in medical records coding from an accredited program, or equivalent combination
of education and experience.
Certification by the Association for the Advancement of Automotive Medicine in Abbreviated Injury Scoring (CAISS) within18 months of hire.
Certified Professional Coder (CPC), Certified Coding Specialist (CSS), or other equivalent coding certification within 18 months of hire is required for Surgery Registrar
Certification in medical coding or Registered Health Information Technician (RHIT)
Experience in trauma or surgery registry abstraction/coding depending on job assignment
Expert skills using Windows-based software (word processing, spreadsheet, databases)
Abstracting experience using current requirements by state and national regulatory bodies
Experience with medical terminology and acronyms related to diagnosis, procedures, complications and comorbid conditions
Experience with accurate and timely data entry and verification to maintain high standards of data quality control