Trauma Registrar

Overview

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

The Emergency General Surgery Registrar is responsible for the emergency general surgery patient identification, collection, entry, validation and maintenance of EGS data for our American College of Surgeons (ACS) verified Level 1 Trauma Center. Utilizing analytical and cognitive skills, the EGS Registrar collects emergency general surgery data used for improvement in clinical care, injury research, national benchmarking, epidemiology, prevention and quality initiatives, performance improvement, and education. The registry professional accurately assigns ICD-10 codes and enters required data into the EGS registry, maintaining HIPAA standards at all times.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Responsibilities

Essential Functions

• Participates in all registry-required activities to obtain and maintain ACS Verification as an Emergency General Surgery Verified Facility.
• Performs thorough review of electronic medical record (EMR) for identification of relevant clinical diagnoses, procedures performed, complications, co-morbidities, and other pertinent EMS and hospital data as required by the ACS.
• Assigns appropriate ICD-10-CM diagnosis, and ICD-10 PCS codes based on currently published standards.
• Collaborates with appropriate entities to assure complete documentation for all required registry data fields.
• Understands and adheres to Official AIS Coding and AAAM coding policies based on currently published standards.
• Understands and adheres to Emergency General Surgery data dictionary definitions on current year required data fields.
• Accurately abstracts pertinent data from the patient medical records, and applied ICD-10 and AIS coding at greater than or equal to 95% accuracy.
• Completes 100% of records within 60 days of patient discharge.
• Participates in re-abstraction/validation of 5-10% of patient records with inter-rater reliability of 95% or greater.
• Prepares, and distributes a daily list of identified emergency general surgery patients to pertinent UUH staff.
• Prioritizes completion of data on all emergency general surgery related mortalities for EGS Quality Review Committee meetings.
• Assigns appropriate activations charges based on current criteria.
• Participates in data reporting for statistics, quality and performance improvement projects, grant submissions, and IRB approved research studies.
• Assists in preparing data for submission to the State of Utah Department of Health.
• Assists in preparing quarterly data for submission to the American College of Surgeons National Safety Quality Improvement Program (ACS-NSQUP).
• Participates in monthly ACS-NSQIP educational quizzes, internal education, and any additional training as needed.
• Participates in Emergency General Surgery meetings, periodic trainings, and on ad-hoc committees.
• Completes twenty-four (24) hours of surgical-related Continuing Education during each ACS verification cycle.
• Participates in Emergency General Surgery related quality initiatives.

Knowledge / Skills / Abilities

• Demonstrated ability to write (if necessary), and run basic reports utilizing the EGS registry.

• Demonstrated teamwork by collaborating with registry staff to meet all required deadlines for data submission and ACS requirements.

• Mastery level knowledge of ICD-10 coding related to emergency general surgery patients.

• Mastery level knowledge of medical terminology, and anatomy & physiology.

• Demonstrated ability to communicate and collaborate effectively with clinical staff and other hospital personnel.

• Knowledge of healthcare IT systems, preferably EPIC, NQS, Microsoft Office.

• Ability to be detail oriented and to prioritize daily tasks.

• Ability to work independently while collaborating with other members of the healthcare team.

• Ability to be self-motivated while working in a HIPAA compliant, remote environment with minimal direct supervision.

Qualifications

Required

• Trauma (or EGS) Registry OR verified ICD10 coding experience or certification(s).
• One (1) year of experience abstracting medical information from EMR.
• Ability to participate in and pass the ACS NSQIP Surgical Clinical Reviewer (SCR) course within one (1) year of hire.
• Ability to participate in and pass the TOPIC Course and ACS Quality Improvement Course within one (1) year of hire.
• Complete 24 hours of trauma-related Continuing Education during each ACS verification cycle.
• Completes ICD-10 refresher course every five (5) years.
• Obtains Certified Abbreviated Injury Scale Specialist (CAISS) within five (5) years of hire.

Qualifications (Preferred)

Preferred

• Trauma or EGS Registry experience.
• Current CCA, CCS, CPC, RHIT or RHIA Certification.
• One (1) year of inpatient coding experience.
• Certified Specialist in Trauma Registries (CSTR).
• Certified Abbreviated Injury Scale Specialist (CAISS).
• Associate or Bachelor degree in a related field.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.

Physical Requirements

Listening, Sitting, Speaking, Standing, Walking