Trauma Registrar Coder 1 -- Trauma Center -- General Hospital

Job Summary

Evaluate patients records and assign appropriate codes. Abstract pertinent data from patients' clinical records. Review records for reimbursement purposes and to ensure quality control.

Remote/Hybrid schedule may be available.

Responsibilities

• Read and interpret medical record entries to identify all diagnoses and surgical procedures.

• Assign appropriate ICD-10-CM and AAAM codes in compliance with recognized coding principles and department policies.

• Identify patients who meet criteria for inclusion in the trauma registry.

• Abstracts data from medical record and other sources. Enters data in Trauma Registry concurrently and retrospectively.

• Perform AIS (Abbreviated Injury Severity) coding and Injury Severity Scoring.

• Verify and correct any data discrepancies by initiating communication with physicians and other hospital personnel.

• Responsible for the accurate and timely entry of all abstracted and coded date into the computer system.

• Provide data and statistical information for performance improvement, trauma education and research, trauma service outreach, and routine trauma service reports.

• Participate in the Trauma Service's quality and performance improvement initiatives.

• Enter all abstracted and coded data into the computer system in an accurate and timely manner.

• Promote and enhance positive customer service and a positive environment.

• Maintains a 95% or greater abstracting accuracy rate.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities

(Essential duties common to all positions)

1. Maintain and document all applicable required education.

2. Demonstrate positive customer service and co-worker relations.

3. Comply with the company's attendance policy.

4. Participate in the continuous, quality improvement activities of the department and institution.

5. Perform work in a cost effective manner.

6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.

7. Perform work in alignment with the overall mission and strategic plan of the organization.

8. Follow organizational and departmental policies and procedures, as applicable.

9. Perform related duties as assigned.

Education

• High School Diploma or GED (Required) Experience: None
• Formalized Training (Required) Education: High School Diploma/GED, Formalized Training in Medical terminology.

Comments: Must score 80% on Medical Terminology & ICD-10-CM Course. Must achieve a rating of exceeds standard at both the midyear and the annual appraisal to advance to a Trauma Registrar Coder II position. Must successfully complete The Association for the Advancement of Automotive Medicine (AAAM) within 1 yr of employment.

Credentials

• Association for Advancement of Auomative Medicine (Required) Within 1 year of hire

Work Schedule: Days

Status: Full Time Regular 1.0

Location: General Hospital

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Tamara B. Young tammy.young@vandaliahealth.org