Trauma Data Analyst- Trauma Registrar

Facility: North Fulton Hospital

Job Summary:

The Certified Trauma Data Analyst is a Trauma Registrar with 5-7 years of trauma registry experience working at a Wellstar Level I or II Trauma Center. This position serves as a coding resource to team members while abstracting and coding records daily. The Trauma Registry is a complex injury and disease specific database that is integral to the operations of the trauma center. Quality Trauma Registry data must be collected by every trauma center and is critical to the success of a trauma program. The Trauma Registrar is responsible for the management of all components of the Trauma Registry, including data collection, data abstraction, data entry, data retrieval/statistical conversion, and data validation. The Trauma Registrar and Certified Trauma Data Analyst positions report directly to Trauma Program Manager. Key responsibilities of the role include: Data abstraction/ entry, database management, inter-rater reliability and data validation, uploading data to state and national trauma registries, analysis of data frequency submission reports, monitoring the database for data integrity and mapping inconsistencies as well as error correction and report writing. Trauma Registry data is vital to daily operations, process improvement, benchmarking and improving the quality of trauma care delivery. Injury Prevention and Outreach events are developed based on the trauma population captured within the Trauma Registry. Ongoing trauma operations including staffing for trauma clinical care units and Trauma Surgery staff is based on trauma volume and trends. There are regulatory and statutory requirements for trauma centers to maintain high quality trauma registries. Trauma Registrars must maintain proficiency in anatomy/physiology, in health information technology, trauma specific software, and knowledge of a variety of trauma scoring/scaling methods is essential. The Trauma Registrar must also have knowledge of two independent coding systems: ICD-10-CM/PCS and Injury Severity Coding (AIS). The Trauma Registrar must also learn EMS procedures and terminology, nursing procedures and terminology, radiology terminology, and understand disease processes for capturing comorbid conditions and complications for the registry according to the National Trauma Data Bank (NTDB). They should also have knowledge of ICD-9-CM/PCS for reports and historical data.

Core Responsibilities and Essential Functions:

Data Abstraction/ Entry Responsible for the abstraction of data from various data sources (electronic health record, Trauma Activation Logs, PI Data sheets, etc.) necessary to complete trauma records within the hospitals’ Trauma Registry database. Utilizes technical coding principles expertise to accurately assign appropriate ICD-10- CM diagnoses and ICD- IO-PCS procedure codes into trauma database to the greatest specificity. Utilize technical trauma specific coding principles expertise to assign appropriate AIS codes used to calculate the ISS (injury severity score). Identify activation levels and report to Charge Capture for appropriate reimbursement. Identifies records that fall within the Trauma Registry inclusion criteria for hospital, state, and national registries. Performs data abstraction and entry using established rules and definitions set by the National Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP), State Registry and the hospitals’ data dictionaries. Informs the Trauma Program Manager (TPM) of all relevant trauma audits filter inconsistencies via monthly Quality Assurance Reports. Informs the Trauma Program Leadership of all opportunities for improvement in trauma related documentation that may be identified during the data abstraction/entry/validation processes. Meets productivity standards. Queries physicians when needed to further clarify code assignments. Data Extraction and Reporting Responsible for the assimilation, extraction, and statistical presentation of all trauma registry data, as required by the ACS, TJC, and as requested by the TPM. Runs appropriate quality assurance reports and takes corrective action on errors in preparation for each data upload. Ensures all data uploads to the NTDB, TQIP, and State Trauma Registry are completed on time and documented for reporting. Produces various other Quality Assurance reports as requested by the TPM. Ensures Trauma Registry Data Request form is completed and approved prior to the running of and release of Trauma Registry data for any entity other than the TPM, in accordance with the Trauma Registry Data Management procedures. Builds Trauma Registry reports to capture data requests from the TMD/ TPM and works with the Trauma Registry vendor to leverage opportunities for more advanced report writing capabilities within the Trauma Registry database. Monitors productivity of Trauma Registry staff. Fields coding questions as needed. Advocates for issue and improvement opportunities on behalf of the Trauma Registry professionals. Data Validation and Inter-rater Reliability Analyzes records for quality assurance trauma standards recommended by the Trauma Committee and as stipulated by the American College of Surgeons (ACS) and the Joint Commission (TJC): Data includes all phases of trauma care (i.e., pre-hospital, emergency department, intraoperative, and inpatient). Maintains the highest level of validity to assure accurate program profiling (i.e., TQIP, state and internal data reports) based on defined processes and maintains an accuracy rate of . Completes routine checks of abstracted data for accuracy. Identifies suspicious or invalid cases, variables, and data values, and implements corrective action for invalid data. Database Management Ensures security and privacy of all Trauma Registry related data in accordance with HIPPA and the Trauma Registry Data Management procedures. Ensures data is collected in compliance with National Trauma Data Standards (NTDS). Expands the database management program as needed to meet the needs of the Trauma Program. Serves as liaison with the registry software vendor and WHS IT department personnel. Ensures all software program updates are completed as needed. Ensures data backups are completed at scheduled intervals. Other Duties Attends all Trauma Services meetings as requested. Participates in the Georgia Committee of Trauma Excellence (GCTE) Trauma Registry Subcommittee. Responsible for continued professional growth: must complete 8 continuing education hours annually as required by the ACS. May include: TQIP Conference TQIP Education Opportunities TQIP Annual course (on-line) Hospital, WHS Trauma Center or state trauma education programs Helps to support regional and state trauma system development. Serves as mentor for trauma registrars locally, system-wide, as well as at a regional and state level.

Required Minimum Education:

Associate's Degree Health Information Management /Technology Required or Other Education • Diploma in Health Information Coding (ICD-10CM, ICD-10PCS) • ATS Trauma Registry Course (or equivalent course for trauma registrars) • AAAM AIS Coding Course Required

Required Minimum License(s) and Certification(s):

Cert Abbr Injury Scale Spec 1.00 Required Cert Specialist Trauma Registr 2.00 Required Reg Health Information Tech 3.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 5 years Trauma Registry experience at a state designated and/or American College of Surgeons verified Trauma Center Required Minimum 3 years at Level I or II Trauma Center Preferred

Required Minimum Skills:

DI/ESO trauma registry experience preferred. Proficient in medical terminology, human anatomy, and surgical procedures. Computer/ data entry experience. Ability to communicate with various members of the healthcare team. Ability to use Microsoft Office Suite and have computer operational knowledge to work with and manage a team in a virtual environment which includes web-conferencing, email, instant messaging, and other forms of digital technology. EMR (electronic medical record) knowledge and navigation experience, Epic, 3M

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