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Completes a variety of Trauma, Burn, and Acute Care Surgery Registry tasks, including data collection, data entry and retrieval, data quality and integrity, data analysis, and display and statistical conversion for the purpose of research, performance improvement, injury prevention, education, billing, and outcome measurements. Obtains, abstracts, and reports appropriate concurrent and retrospective patient data on Trauma, Burn, and Acute Care Surgery patients. Uses Abbreviated Injury Scaling (AIS) coding of injuries and ICD10 coding of diagnoses and procedures to maintain the Trauma, Burn, and Acute Care Surgery patient databases. Upholds the mission, vision, values, and customer service standards of the UC Health System.
Job Function: Data Abstraction:
• Obtains, abstracts, and enters all appropriate patient-related information into the appropriate databases in an accurate and timely manner by:
o Obtaining information by monitoring daily trauma patient admissions, transfers, and discharges, and confirming all patients and patient changes on the registry, autopsy, and patient identification logs.
o Coordinating the collection of data from various sources, including but not limited to EPIC and its integrated medical record contents, EMS run report databases, and the coroner.
o Analysis and entering appropriate data into registries, including entering all patients from the patient identification reports into the registry.
o Requesting and entering autopsy report data.
o Abstracts and records 300+ data elements, including hospital events/complications, comorbidities, and the TQIP Measures of Processes of Care per the National Trauma Data Standard’s definitions and criteria.
o Ensuring that data is abstracted to meet data deadlines for the UC Health trauma and hospital quality committees, the American College of Surgeons (ACS) National Trauma Data Bank registry, the Ohio Trauma Acute Care registry, the Tri-State Trauma Coalition, and the American Burn Association.
o Participates in ongoing clinical research program’s data collection.
Coding:
• Assigns ICD10 codes for all diagnoses and procedures to maintain the Trauma, Burn, and Acute Care Surgery patient databases. Assigns Abbreviated Injury Scaling (AIS) codes to all injuries per the American Association for the Advancement of Automotive Medicine (AAAM) rules and guidelines.
Continuing Education:
• Keeps current with trends, developments, and practices in the field as they relate to this work assignment; completes eight hours of trauma registry-related continuing education per year as required by the ACS.
Validation:
• Performs monthly and ad-hoc validation of registry data to maintain consistency and quality of data collection for continuous quality improvement and research purposes. Assists in performing inter-rater reliability validation of registry data.
• Achieving and maintaining a validation accuracy rate of 90% or higher.
Financial Reporting:
• Analysis and reporting of UB-04 FL 14 (Type 5) trauma admission type to identify trauma patients with a trauma activation. Performs proper assignment of Epic Registry FYI codes to automate UB-04 68x reimbursement codes for trauma activations with hospital prenotification. Analysis and reporting of UB-04 208 trauma ICU reimbursement code
Confidentiality:
• Maintains compliance with Health Insurance Portability and Accountability Act (HIPPA) requirements. Maintains the confidentiality of patient information.
• Performs other functionally related duties as assigned.
Minimum Required: Associate degree in healthcare, technology, education, Health Information or related field. ***
.| LICENSE & CERTIFICATION: Successful completion of the following courses within in 12 months of hire:
a) An Abbreviated Injury Scaling (AIS) Coding course from the Association for the Advancement of Automotive Medicine (AAAM).
b) The American Trauma Society Registrar Course or State equivalent required by the American College of Surgeons that includes content on abstraction, data management, reports/reports analysis, data validation, and HIPAA.
Possession of one or more of the following certifications preferred:
• Certified Specialist in Trauma Registry (CSTR)
• Certified Abbreviated Injury Severity Scale Specialists (CAISS)
• Certified Inpatient Coder (CIC) from the American Academy of Profession Coders (AAPC)
• Certified Coding Associate (CCA) from the American Health Information Management Association (AHIMA)
• Certified Coding Specialist (CCS) from the American Health Information Management Association (AHIMA)
• Registered Health Information Technician (RHIT) from AHIMA
• Registered Health Information Administrator (RHIA) form AHIMA
YEARS OF EXPERIENCE: Minimum Required: 1 - 2 Years equivalent experience. Preferred: 3 - 5 Years equivalent experience.
*** Two years or more of Trauma Registry Experience or equivalent in lieu of Associate’s degree.