Trauma Registrar - Trauma Center

Trauma Registrar - Trauma Center

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together. About Duke University Hospital Pursue your passion for caring with Duke University Hospital in Durham, North Carolina, which is consistently ranked among the best in the United States. The largest of the four Duke Health hospitals with 1062 patient beds, it features comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center, an endo-surgery center, and more.

General Description of the Job Class A trauma registrar collects, analyzes, and reports on data related to patients who have suffered a traumatic injury. They are responsible for maintaining a trauma registry database that tracks the care and outcomes of trauma patients. Trauma registrars collaborate with trauma teams, hospital staff, and external agencies to ensure the quality and accuracy of trauma data and to improve trauma care and prevention.

Duties and Responsibilities of this Level Maintains the Duke University Hospital (DUH) trauma registry database through the identification, collection, coding, and scoring of trauma patient information. Position collaborates closely with Trauma Center staff to maintain the efficient operations of hospital, state, and national trauma registries. Interprets data for research projects. Ensures adherence to data management protocols set forth to ensure regulatory compliance standards and maintain Level 1 trauma status. Assists with quality control activities, information requests, and quality improvement studies as requested.

Level I - Trauma Registrar Identification, abstraction, from the medical record, and entry into the trauma database, on each trauma patient meeting trauma registry database qualification. Analyzing data for accuracy and validating for submission to the state and national databases prior to mandated submission date. Coordinate with outside agencies to obtain medical records. Participate in local, state, and national meetings and conferences as required by state and national regulations. Must obtain a minimum of 8 hours per year of external trauma registry education.

Level II - Trauma Registrar Performs all duties of the Level I - Trauma Registrar. Independently research and solve complex coding problems. Serve as coach and educational resource to Level I Trauma Registrars. Ability to run and validate complex reports through the trauma registry's report writer. Interpret data and review reports for performance improvement, support of related programs, administrative planning and marketing, research purposes, and regulatory visits.

Level III - Lead Trauma Registrar Performs all duties of the Level I and II - Trauma Registrar. Facilitates the orientation and onboarding process for new registrars. Onboarding of new staff to ensure that all standards of training are met. The onboarding will include orientation to the registry, electronic medical record, national trauma databank and state criteria, TQIP and internal processes. Oversee all components of the trauma registry, including data collection, data entry, quality, integrity, and analysis. Analyzes data for accuracy and validating for submission to the state and national databases in accordance with established matrix. Ensures DUH data is provided as required to local, state and national databases/programs. Maintains system upgrades. Serves as primary contact for TQIP program and trauma registry vendor. Coordinate with outside agencies to obtain required information to meet standards as determined by the State of North Carolina and the American College of Surgeons. Assists with preparation for state/ACS site survey visits to include ensuring validation of data, chart pull, PRQ preparation and completion. Available on site for assistance at time of all designation/verification reviews. Collaborate with software vendor and IT services to ensure the continuing function of the trauma registry database by making necessary changes both internally and externally. Maintain registry chart completion rate at 80%, or above, for compliance of 60 days complete post discharge. Provide bi-annual TQIP review to identify opportunities for dissemination with Trauma Medical Peer Review group and hospital leaders for awareness of benchmarking. Collaborates with Trauma Medical Director (TMD) and Trauma Program Manager (TPM) to analyze data and identifies trends in data. Participates in trauma meetings as assigned. Develop ad hoc reports as requested. Assists with preparation of annual report for Trauma Service. Prepares graphs and data presentations that highlight trends and presents to appropriate audience. Able to present data in group settings. Able to analyze and identify trends in provider's record and reports to TMD/TPM. Able to independently format reports. Identifies deficiencies in standards and works to improve compliance. Identifies trends noted through chart review and communicates to TMD/TPM. Provide continued educational support of existing staff at trauma registry meetings and be a resource for level I and II registrars. Participates in Trauma Program Performance (TPP), RAC meeting, and other meetings as requested and or assigned. Leads Trauma Registry meetings and serves as mentor and resource for questions, concerns and issues as it relates to the trauma registry. Works with researchers to understand DUH trauma data availability and prepares reports for research as requested.

Required Qualifications at this Level Education Level I - High School diploma, or GED required. Level II - High School diploma, or GED required. Level III (Team Lead) - High School diploma, or GED required. Associate's degree in Business, Computer Science, or healthcare related field, preferred. Experience Level I One-year experience as a Trauma registrar, or similar health-related experience such as a RN, EMT, CNA, medical coder, HIM, etc. preferred. Level II At least 18-months experience as a Trauma registrar required. Level III 3-years of experience as a trauma registrar required; preferably in North Carolina. 1-year of Level 1 trauma center experience required. Trauma specific ICD-10-CM and PCS training within the past 5 years required. Degrees, Licensure, and/or Certification Level I Successful completion of the American Trauma Society's (ATS) registry course within 12 months from date of hire. Successful completion of a trauma specific ICD-10-CM and PCS course within 12 months from date of hire. Successful completion of the Association for the Advancement of Automotive Medicines' (AAAM) injury scale course within 12-months from date of hire. Successful completion of the CSTR exam within 18-months from date of hire. Maintains licensure/certification as a healthcare professional such as a RN, EMT, medical coder, RHIT, HIM, CNA etc., if applicable. Level II Certified Specialist in Trauma Registries (CSTR) certification required. Successful completion of the American Trauma Society's (ATS) registry course. Successful completion of the Association for the Advancement of Automotive Medicines' (AAAM) injury scale course. Trauma specific ICD-10-CM and PCS training within the past 5 years required. Maintains licensure/certification as a healthcare professional such as an RN, EMT, medical coder, RHIT, HIM, CNA etc., if applicable. Level III Certified Specialist in Trauma Registries (CSTR) certification required. Certified Abbreviated Injury Scale Specialist (CAISS) certification required. Successful completion of the American Trauma Society's (ATS) registry course. Successful completion of the Association for the Advancement of Automotive Medicines' (AAAM) injury scale course prior to hire. Trauma specific ICD-10-CM and PCS training within the past 5 years required. Maintains licensure/certification as a healthcare professional such as an RN, EMT, medical coder, RHIT, HIM, CNA etc., if applicable. Knowledge, Skills, and Abilities A high degree of skill is need in the following areas: independence and self-direction, strong degree of interpersonal skills, critical thinking, decision making, problem solving, working knowledge of Microsoft office to include above average knowledge in Word and Excel. Previous experience in chart auditing, ICD9 and 10 codes, medical procedure coding strongly preferred. Knowledge of basic medical terminology, anatomy, and physiology. Must be able to work independently but function well within a team. Demonstrates ability in successful interpersonal communication and customer service skills. Distinguishing Characteristics of this Level N/A The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description. Duke University is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, (including pregnancy and pregnancy related conditions), sexual orientation, or military status. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values. Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.