VCU Health
Overview
The Trauma/Surgery Registrar supports the VCU Health System’s adult or pediatric Trauma and Surgical Programs and organizational requirements for verification as a Level 1 Trauma/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 and abstraction of data from various sources including the electronic medical record, prehospital databases, and other data sources.
Responsibilities
Assign ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities and complications according to methodologies and coding rules.
Perform ongoing daily chart reviews on all patients and enter data into the Registry.
Report complications and quality issues to the Supervisor.
Ensure adherence to data management protocols to ensure accurate and timely reporting of data to the organization and regulatory agencies.
Assist with performance improvement activities.
Licensure, Certification, or Registration Requirements for Hire
Certified Professional Coder (CPC); Certified Coding Specialist (CCS); or equivalent coding certification or Registered Health Information Technician (RHIT) preferred.
Licensure, Certification, or Registration Requirements for Continued Employment
Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 18 months of hire is required for Trauma Registrars.
Certified Professional Coder (CPC), Certified Coding Specialist (CSS), or other equivalent coding certification within 18 months of hire is required for Surgery Registrars.
Experience
Required: One (1) year work experience in 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.
Preferred: 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.
Education/Training
Required: Associate’s Degree in any field that includes two semesters of medical terminology and Anatomy/Physiology, or in medical records coding from an accredited program. Work experience may be considered in lieu of credentials not required by law with HR approval. Specific to role, work experience must be considered.
Preferred: Completion of ICD-10 coding courses.
Independent Action 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 handles patients of basic to moderate complexity, including patients with multiple complications, including deaths.
Supervisory Responsibilities N/A
Additional Position Requirements
Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.
Age Specific Groups Served N/A
Physical Requirements
Physical lifting less than 20 lbs.
Activities: Prolonged sitting, repetitive motion (keyboard, mouse).
Mental/Sensory: Strong recall, reasoning, problem solving, hearing, clear speech, legible writing, reading, logical thinking.
Emotional: Fast-paced environment, steady pace, able to adapt to frequent change.
Work Environment and Compliance Rotating
EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.
#J-18808-Ljbffr
Responsibilities
Assign ICD-10 diagnosis codes and other specialized coding (including Abbreviated Injury (AIS) Scores) to procedures, comorbidities and complications according to methodologies and coding rules.
Perform ongoing daily chart reviews on all patients and enter data into the Registry.
Report complications and quality issues to the Supervisor.
Ensure adherence to data management protocols to ensure accurate and timely reporting of data to the organization and regulatory agencies.
Assist with performance improvement activities.
Licensure, Certification, or Registration Requirements for Hire
Certified Professional Coder (CPC); Certified Coding Specialist (CCS); or equivalent coding certification or Registered Health Information Technician (RHIT) preferred.
Licensure, Certification, or Registration Requirements for Continued Employment
Certification by the Association for the Advancement of Automotive Medicine as an Abbreviated Injury Scale Specialist (CAISS) within 18 months of hire is required for Trauma Registrars.
Certified Professional Coder (CPC), Certified Coding Specialist (CSS), or other equivalent coding certification within 18 months of hire is required for Surgery Registrars.
Experience
Required: One (1) year work experience in 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.
Preferred: 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.
Education/Training
Required: Associate’s Degree in any field that includes two semesters of medical terminology and Anatomy/Physiology, or in medical records coding from an accredited program. Work experience may be considered in lieu of credentials not required by law with HR approval. Specific to role, work experience must be considered.
Preferred: Completion of ICD-10 coding courses.
Independent Action 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 handles patients of basic to moderate complexity, including patients with multiple complications, including deaths.
Supervisory Responsibilities N/A
Additional Position Requirements
Must be willing and able to work evenings and weekends when necessary based on case volumes and state/national verification site surveys.
Age Specific Groups Served N/A
Physical Requirements
Physical lifting less than 20 lbs.
Activities: Prolonged sitting, repetitive motion (keyboard, mouse).
Mental/Sensory: Strong recall, reasoning, problem solving, hearing, clear speech, legible writing, reading, logical thinking.
Emotional: Fast-paced environment, steady pace, able to adapt to frequent change.
Work Environment and Compliance Rotating
EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.
#J-18808-Ljbffr