Clinical Data Registrar (Trauma)

Licensure, Registration, and/or Certification Required:

• RHIA, RHIT, or CAISS credential and experience in Level one Trauma Center.

Education Required:

• Associate's Degree in Health Information Management or related field.

Experience Required:

• Typically requires 1 year of experience in data collection that includes experiences in coding/abstracting and clinical documentation.

Major Responsibilities:

• Performs review of complex clinical records to secure data for inclusion into the formal longitudinal registries required by the organization.
• Uses appropriate classification and coding systems via computerized software, within the time frames required by local, state and national mandates.
• Abstracts high integrity information from the internal medical record and conducts concurrent and or retrospective review of external medical records in order to facilitate complete analysis, monitoring and reporting of quality data.
• Performs interoperability and reliability testing and utilizes various data quality monitoring techniques to reconcile and validate information according to registry and internal data quality standards and data dictionaries.
• Completes the process for timely submission of data at appropriate intervals to the various advanced and complex disease/procedure specific specialty databases and other registries as required for compliance with membership and professional standards. Coordinates multi-disciplinary weekly case conferences, preparing notices, summations and submits all required Continuing Professional Development department post-conference documentation for CME.
• Develops, performs, and evaluates quality improvement activities for the registries ensuring a percent of abstracted data is physician and peer reviewed on an annual basis.
• Performs follow-up of appropriate registry patients over their life-time as required, maintaining the accuracy and integrity of the data for use in end-results, financial, market, research and quality reporting.
• Establishes and maintains effective working relationships with physicians and care management staff working together to compile registry data into meaningful reports/displays, and promotes the use and visibility of the information collected.
• Prepares and assists with studies for publication, audits, and annual reports in a timely fashion.
• Prepares and assists in developing and updating Registry "Policies and Procedures" on a yearly basis and Complies with accrediting agency requirements.

Knowledge, Skills & Abilities Required:

• Knowledge of medical terminology, anatomy and physiology and pathophysiology.
• Knowledge of computer applications, computer function and basic statistical methods.
• Ability to follow detailed coding instructions and specifications with minimal supervision.
• Ability to work independently with a high degree of accuracy and attention to detail.
• Ability to communicate well orally and in written format.
• Ability to travel as needed with exposure to road and weather conditions.
• Ability to spend extended periods of time (75% of the workday) in sedentary work.
• Ability to operates all equipment necessary to perform the job.
• Ability to secure required credentials according to internal and external requirements for abstraction.
• Exposed to a normal office environment.

Physical Requirements and Working Conditions:

• Exposed to a normal office environment.
• Exposure to road and weather conditions.
• Ability to spend extended periods of time (75% of the workday) in sedentary work.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

#LI- RHIT

#LI- CAISS

#LI-RHIA

#LI- Trauma Coding