Inspire health. Serve with compassion. Be the difference.
Job Summary
All employees are expected to be knowledgeable and compliant with Prisma Health’s values of compassion, dignity, excellence, integrity and teamwork. This job is responsible for the identification of trauma patients meeting registry inclusion criteria, abstracting clinical and outcomes data from the medical record, coding diagnoses, procedures, and injuries utilizing ICD-10 coding, AIS coding, E-Codes, and entering data into the Trauma Registry per National Standards and State Standards/State Trauma Regulations published by the American College of Surgeons (ACS), National Trauma Data Bank (NTDB) and SC Department of Health and Environmental Control (DHEC). Performs data analysis on Trauma Registry data for monitoring data quality and performs data analysis and writes reports to support the activities of the Trauma Program such as performance improvement, research, administrative and medical staff meetings, injury prevention, and Trauma Center Designation/Verification process.
Essential Functions
All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.
Accurately identifies patients for inclusion in the trauma registry as specified by the National Trauma Data Standard (NTDS), State Trauma Registry, and Trauma Center.
Accurately abstracts clinical data from Emergency Management System (EMS) Patient Care Record (PCR), in-patient medical record, referring hospital records and autopsy reports including patient demographics, injury event, pre-hospital information, injury diagnoses, operative and other procedures, ED data, co-morbidities, complications, patient outcome and financial data as defined by State Trauma Registry, NTDS, and Trauma Quality Improvement Program (TQIP). Accuracy and completion timeliness rates must meet or exceed established department goals.
Accurately codes all diagnoses, procedures and external cause/location of the trauma patient using AIS coding and ICD-10 coding following trauma center, State Trauma Registry, NTDS, and TQIP guidelines.
Actively participates in the PI process and supports research by gathering data on hospital specific performance and research metrics. Identifes and reports complications, comorbidities, issues and trends identified to leader.
Performs data validation and correction of registry data at the close of each chart using the registry software validation tool. Performs logic validations monthly and makes corrections. Performs data corrections as needed per validation reports and prior to State and Trauma TQIP data submission. Completes assigned inter-rater validations.
Performs other duties as assigned.
Supervisory/Management Responsibilities
Minimum Requirements
Education - Associate's degree in HIM or related healthcare field preferred.
Experience - One (1) year of trauma registry, coding, HIM or relevant healthcare related experience.
Requires completion of AAAM course (AIS coding) and Trauma Registry Course within one (1) year of hire.
Requires ICD-10 Coding course within one (1) year of hire.
In Lieu Of
Required Certifications, Registrations, Licenses
One of the following certifications is preferred: CSTR (Certified Specialist in Trauma Registries) from the American Trauma Society or CAISS (Certified Abbreviated Injury Scale Specialist) from the Assoc. for the Advancement of Automotive Medicine (AAAM).
An AHIMA (American Health Information Management Assoc) or AAPC (American Academy of Professional Coders) coding certification preferred.
RHIT, RHIA, or CCS preferred.
Knowledge, Skills and Abilities
Work Shift
Day (United States of America)
Location
Greenville Memorial Hospital
Facility
1008 Greenville Memorial Hospital
Department
10087001 Trauma Program
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