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Job Summary
Performs advanced clinical data abstraction for a Level I Trauma Center in support of state and national trauma registry participation, research, performance improvement, and regulatory compliance. This role requires deep knowledge of trauma systems, complex injury patterns, and Level I verification standards. The ideal candidate demonstrates expert judgment, precision in coding and abstraction, and the ability to work independently in a high-acuity trauma environment.
Responsibilities
- Identify, analyze, and abstract comprehensive trauma patient data from multiple clinical and administrative sources, including EHRs, operative reports, EMS documentation, and ancillary systems.
- Organize and enter detailed injury and care data into the trauma registry database, capturing mechanism of injury, severity, clinical course, interventions, complications, and outcomes in accordance with Level I standards.
- Abstract all required data elements for trauma patients meeting registry inclusion criteria, ensuring completeness, accuracy, and timeliness.
- Assign Injury Severity Scores using AIS methodology and accurately code diagnoses and procedures using ICD-10-CM and ICD-10-PCS.
- Apply advanced clinical knowledge to abstract complex cases, including multisystem trauma, transfers, deaths, and research-eligible cases.
- Participate in internal and external quality assurance processes, including data validation, audits, discrepancy resolution, and preparation for ACS verification or state review.
- Collaborate with trauma program leadership, performance improvement teams, and clinical staff to clarify documentation and support trauma program goals.
- Maintain current knowledge of trauma care, registry standards, and regulatory requirements to ensure continued compliance with Level I Trauma Center expectations.
Qualifications
- Level I Trauma Center experience required.
- Advanced understanding of trauma systems, injury scoring, and registry rules.
- Excellent written and verbal communication skills with strong clinical documentation interpretation ability.
- Exceptional attention to detail and data accuracy.
- Ability to work independently in a remote environment while meeting productivity and quality standards.
- Current on all required trauma registry and coding education.
- Documentation of completion of the Trauma Registry Course required.
- Documentation of completion of the AAAM AIS Coding Course required.
- Documentation of ICD-10 coding course completion within the last five years required.
- Certified Abbreviated Injury Scale Specialist (CAISS) and Certified Specialist in Trauma Registries (CSTR) preferred.