Trauma Registrar (Remote)

Job Description Summary

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Job Description

Minimum Requirements:

High school diploma with experience in medical terminology required. A medical records course to include ICD-CM or AIS and one year related experience, or Associate degree in coding, preferred.

Experience in data entry preferred. Familiarity with chart abstraction helpful. Experience with EPIC electronic medical record and Image Trend Patient Registry is helpful. Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Abbreviated Injury Scale Specialist (CAISS) and/or Certified Trauma Registrar (CSTR) preferred. 

Job Responsibilities 

Collect, compile and maintain concurrent accurate data in the Trauma Registry. (Weight: 50%) 

Success Criteria:  

• Ensure accurate current AIS/ICD-CM coding required by the National Trauma Data Bank, American College of Surgeons and the Abbreviated Injury Scaling system on all trauma patients. 
• Maintain daily trauma database of patients admitted to MUSC meeting the National Trauma Data Bank and South Carolina DHEC inclusion criteria. 
• Abstract and analyze information from Epic, EMS Patient care records, outside hospital transfer records and any other sources of documentation that may be available to capture accurate patient information into the Trauma Registry. 
• Demonstrate knowledge of current ICD-CM, AIS, Glasgow Coma Scale, Revised Trauma Score, Probability of Survival and Trauma and Injury Severity score. 
  Demonstrate knowledge of anatomical and medical terminology used frequently with trauma patients. 

Collaboration to help improve TQIP scoring and performance improvement. (Weight: 25%) 

Success Criteria: 

• Identify, document and discuss complications, PI issues, and noted variances in data while reviewing and analyzing charts. 
• Report identified issues and trends directly to the department’s management. 

Trauma Registry data integrity (Weight: 25%) 

Success Criteria: 

• Analyze and identify errors and omissions in data entry using Inter-Rater Reliability. 

Additional Job Description

NOTE: The following descriptions are applicable to this section: 1) Continuous – 6-8 hours per shift; 2) Frequent – 2-6 hours per shift;  3) Infrequent – 0-2 hours per shift

Physical Requirements:

Ability to perform job functions while standing. (Infrequent) 
Ability to perform job functions while sitting. (Frequent) 
Ability to climb stairs. (Infrequent) 
Ability to work indoors. (Continuous) 
Ability to perform ‘pinching’ operations. (Infrequent) 
Ability to fully use both hands/arms. (Continuous) 
Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (Frequent) 
Ability to reach in all directions. (Continuous) 
Possess good finger dexterity. (Continuous) 
Ability to lift and carry 30 lbs., unassisted. (Frequent) 
Ability to lift /lower objects 30 lbs. from/to floor from/ to 36 inches unassisted. (Frequent) 
Ability to lift from 36 inches to overhead 30 lbs. unassisted. (Frequent) 
Ability to push/pull objects to 30 lbs., unassisted. (Frequent) 
Ability to maintain 20/40 vision, corrected, in one eye or with both eyes. (Continuous) 
Ability to see and recognize objects close at hand. (Continuous) 
Ability to match or discriminate between colors. (Infrequent) 
Ability to determine distance/relationship between objects; depth perception. (Continuous) 
Ability to perform gross motor functions with frequent fine motor movement. (Continuous) 
Ability to work in a latex safe environment. (Continuous) 
Ability to be qualified physically for respirator use, initially and as required. (Continuous) 

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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