The Trauma Registrar is responsible for collecting, abstracting, coding and reporting data regarding patients with traumatic injuries. Incumbent reviews medical records and communicates with trauma team staff to identify reportable cases and to collect information related to severity and cause of injury and course of care and outcome, and codes and enters the data into the New York State Trauma Registry database according to program guidelines. This is a remote contract position. Must be able to work 40 hours per week.

Responsibilities:

Reviews a variety of medical records to collect information related to trauma patients Identifies patient records that meet criteria for inclusion in the New York State Trauma Registry, using ICD diagnosis and other criteria defined by the Registry Reads and interprets the various components of the medical record, such as physician documentation, radiology reports, laboratory reports and all treatment modalities, in order to abstract and code for entry into the Trauma Registry Database Prepares exclusion report for Trauma Registry when appropriate Researches additional information not given in medical record by, for example, contacting other physicians or institutions Obtains follow-up information for entry into database Maintains the components of the trauma related data collection system consistent with all regulatory and procedural policies Performs quality control activities and ensures accuracy of data Runs, compiles and distributes a variety of routine and specialized reports for hospital administration and staff Participates in all functions related to Trauma Registry, as required.

Qualifications/Requirements:

Three years of experience in a hospital or health care facility where the primary function of the position was obtaining, coding and reporting trauma information using

ICD-9, ICD-10

CPT or HCPCS codes, required CPC, preferred. CSTR and CAISS (required within 2 years of employment) Knowledge and understanding of the guidelines of the New York State Trauma Registry for trauma abstracting. Knowledge of medical terminology; good knowledge of the ICD codes; ability to read, understand and apply the appropriate guidelines for trauma abstracting; ability to accurately abstract and stage information from the various components of patient medical records; ability to understand and code medical records. #INDWP