Trauma Registrar

About Us:

AE & Associates, LLC was founded in 2000 by Arnold and Ester Ardevela, a husband-and-wife medical team, in response to the growing demand for health information and quality management services. Based in Corona, California, they began AE & Associates in response to a growing need for interim staffing of credentialed healthcare professionals in the Inland Valley. Our mission is to support healthcare organizations and professionals by providing high quality staffing services through our credentialed and experience health information professionals. Our mission is also to be the premier provider of a wide range of healthcare services designed to meet the current and future needs of our current and potential healthcare clients across a broad geographical area.

Job Title:

Trauma Registrar

Description/ Responsibilities:

The Trauma Registrar is responsible for reviewing, interpreting, coding and abstracting medical records information according to standard classification system; identifying diagnostic categories based on medical, diagnostic and related hospital services rendered and other related patient information; reviewing medical records for adherence to quality standards; and performing other related duties as assigned by client.

Job Duties:

Duties may include, but are not limited to, the following:

• Depending upon assignment, reviews and codes inpatient and/or outpatient medical record information; assigns codes using ICD-10-CM, CPT, and/or HCPCS codes and modifier assignments; identifies and codes secondary diagnoses and/or procedures; ensures compliance with all NTDB and TQIP reporting requirements. Compile and enter data into the trauma registry by analyzing, identifying, interpreting, and abstracting the data from the patient’s medical record compile the information for abstraction into the trauma registry. Assign and score all injuries utilizing the AIS-15 (Abbreviated Injury Scale).Operates the Trauma Registry in a concurrent manner, at minimum, 80% of cases must be entered within 60 days of discharge.
• Participate as an integral member of the Trauma Services Improvement Committee (SIC)
• Evaluates the quality of clinical documentation on a continuous basis to identify incomplete or inconsistent documents for inpatient and/or outpatient encounters; brings concerns to the attention of the Trauma Program Director for resolution. Maintains knowledge of current and required coding certifications as appropriate. Create, revise, and update the client’s Trauma One Metrics Data dictionary, ensuring the client is meeting National Trauma Data Bank (NTDB) requirements. Participate and assist in preparing data for National Trauma Data Bank (NTDB)/ Trauma Quality Improvement Program (TQIP) quarterly submission. Audit data entered into the trauma registry utilizing established metrics.
• Ensures patient and hospital confidentiality by maintaining HIPAA compliance, reports areas of concern to the Trauma Program Director. Ensures compliance with NTDB required standards. Completes mandatary 4 hours of registry specific training per year in addition to other continuing education requirements mandated for licensure and certification.
• Assists the Trauma Program Director in performing data quality reviews and interrater reliability on inpatient and/or outpatient records to validate ICD-10-CM, and other codes; verifies e-code appropriateness; checks for missed secondary diagnoses and procedures and ensures compliance with all NTDB mandates and reporting requirements. Validate data by participating in inter-department inter-rater reliability activities on a monthly basis (re-abstract 5-10% of patient records and establish levels of inter-rater reliability; report generation to ensure the validity of the data dispensed for trauma research, performance improvement, and system.
• Assist the Trauma Program Director in performing data quality reviews on outpatient encounters to validate the ICD-10-CM, CPT, and HCPCS level II code and modifier assignments; checks for missed secondary diagnoses and/or procedures; compile and analyze administrative reports for regulatory agencies, participating institutions, and committees as directed by the Trauma Medical Director or Program Manager.
• Stays informed about transaction code sets, HIPAA requirements and other future issues impacting the coding function; keeps abreast of new technology in coding and abstracting software and other forms of automation issues. Prepare data and trends for presentation at national, state, and local meetings. Represent the trauma center at national, state, and local meetings, as requested by the Trauma Medical Director or Program Director. Serve on local, state, and national committees as requested by the Trauma Medical Director or Program Director.
• Demonstrates competency in the use of computer applications, particularly the coding and abstracting software and hardware currently in use by the Trauma Department division.
• Participate in American College of Surgeons (ACS) Consultative and Verification reviews.
• Compiles statistics and prepares/maintains a variety of records and reports; researches and locates missing data and records needed for coding and abstracting; retrieves files and records.
• Performs other related duties as assigned.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily within the scope of practice, and Client’s policies, procedures, and protocols. The requirements listed are representative of the knowledge, skill, and/or abilities required.

Education:

Minimum of High School Degree or GED equivalent

Certifications/ License:

Possession of a national certification from AHIMA as Certified Coding Specialist (CCS), a Registered Health Information Technician (RHIT), or a Registered Health Information Administrator (RHIA)

OR

Possession of a national certification from AAPC as Certified Professional Coder (CPC) or Certified Professional Coder – Payer (CPC-P)

Experience:

One year of experience which has involved either work with medical coding and/or billing; or the analysis/evaluation of technical reports/information to determine appropriate coding.

Physical:

Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles such as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Technical:

Knowledge of Trauma One abstracting system - Preferred

Additional Qualifications:

· Medical recording keeping principles and practices; the nature and uses of medical records charges; basic medical terminology, anatomy and physiology.

· Basic functions of a hospital medical records division; legal aspects of medical record administration. Knowledge and understanding of HIPAA.

· ICD-10-CM, CPT, HCPCS Level II coding systems and AIS (Abbreviated Injury Scale). The APC structure and regulatory requirements.

· Knowledge of general requirement to maintain the trauma registry and ensuring compliance with the American College of Surgeons (ACS) stands and California Title 22 Trauma requirements related to trauma data requirements and the trauma registry.

• Basic keyboard operations and the operation of standards office equipment; standard business computer hardware and software.
• Minimal knowledge of billing as it relates to modifiers.
• The business and professional relationships and ethics involved among hospitals, physicians, and patients.
• Read, interpret and evaluate complex technical reports and information.
• Understanding of National Trauma Data Bank (NTDB) Trauma Inclusion Criteria
• Maintain records and compile statistics.
• Communicate clearly and concisely; both orally and in writing; prepare reports and other written communications.
• Provide excellent public relations and courteous customer service; establish and maintain cooperative working relationships with others including physicians, nurses, administrators, managers, vendors, contractors and other health care industry personnel.

Job location:

This is a remote position (However, candidates must reside from one of the following states- CA, NV, AZ, WA, NE, IL, NY, NJ, PA, FL)

Full Time, Part Time, or either‐one?

Full-Time, Non-exempt

Benefits offered, if qualified

Health insurance

Dental insurance

Vision insurance

Paid time off (State Required, if applicable)

401(k)

401(k) matching

Disability insurance Life insurance

Remote/ Work from home

What is the schedule for this job?

Monday to Friday

8:00am – 4:30pm PST

What is the rate for this position?

$35 - $40 / hour

AE & Associates, LLC is an Equal Employment Opportunity employer. AE & Associates, LLC prohibits any form of unlawful harassment or discrimination against applicants for employment or employees on the basis of race, color, religion, ancestry, sex, gender identity, gender expression, pregnancy, national origin, age, marital status, familial status, military/veteran status, disability status, genetic information with respect to the applicant or employee, sexual orientation, or any other classification/characteristic protected by applicable federal, state or local law.

Job Type: Full-time

Pay: $35.00 - $40.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Vision insurance

Schedule:

• Monday to Friday

Supplemental pay types:

• Bonus opportunities

Work Location: Remote