HIM Trauma Registrar - Trauma Services, University Hospital

Job Title

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area.

Responsibilities

Abides by all compliance requirements and policies and performs these responsibilities in an ethical manner, consistent with the organization's values. Adheres to hospital policies including confidentiality. Reviews Emergency Department registration and/or admission records daily to identify trauma admissions for entry into the trauma registry software. Screens death reports for inpatient, outpatient surgeries, and emergency records for trauma case identification. Reviews electronic medical records to assess information required for abstraction. Reviews records for data collection and quality improvement according to standards outlined by the Trauma Medical Director, Trauma Program Manager and American College of Surgeons. Obtains core information for the patients' medical records, specified by the American College of Surgeons, Trauma Medical Director and Trauma Program Manager, and enters information into approved software. Maintains the confidentiality and security of patient data stored in the Trauma Registry. Codes trauma specific injuries as well as AIS scoring. Maintains quality control of case finding, abstracting, coding, and data processing procedures. Follows established procedures for manual and/or computer retrieval of trauma data. As assigned, answers requests for data. Prepares special and routine reports which summarize the trauma experience of the hospital. Complies data relative to patient care in all phases of care (i.e., pre-hospital, Emergency Department, and acute in-patient care.) for inclusion into the monthly Quality Improvement Program as needed. Attends weekly trauma conferences and transcribes and maintains official minutes. Maintains accurate and complete records by: Maintaining accurate logs and other reports as required. Utilizing the correct documentation tools and procedures. Concurrency rounding with trauma team when applicable. Verifies that information sent via fax machine was done so without error, by reviewing the fax log. Communicates and uses appropriate customer relation skills with physicians, patients, families, and healthcare team in person, via telephone, via email, via fax, and other methods of communications. Informs/relays information to incoming shifts regarding any unfinished requests/duties. Sends emails within the organization and outside the organization in a secure format. Accepts and completes all duties positively and without conflict. Cooperates, helps others, and improves the performance of the unit. Completes all mandatory unit, educational, and hospital requirements. Utilizes cost effective practices in performing all aspects of the job. Complies with Hospital approved dress code found on PolicyStat. Completes all mandatory department, educational and hospital requirements. Adheres to current Infection Control and Safety Standards. Regular and prompt attendance. Ability to work schedule as defined and overtime as required. Related duties as assigned.

Qualifications

High School Diploma or equivalent and 2 years of related experience in Health Information Management Required. RHIT - Registered Health Information Technician preferred and will substitute for the required experience or RHIA - Registered Health Information Administrator preferred and will substitute for the required experience. Comparable combination of education and experience may substitute for the above requirements.

Knowledge, Skills, and Abilities

Knowledge of ICD-10-CM and AIS coding. Completes mandatory 8 hours of registry specific training per year.

Equal Employment Opportunity/Affirmative Action Employer

The University of South Alabama is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, pregnancy, sexual orientation, gender identity, gender expression, religion, age, genetic information, disability, protected veteran status or any other applicable legally protected basis. EO Employer minorities/females/veterans/disabilities/sexual orientation/gender identity.