Coder/Abstractor, Trauma Center

Job Description

The Coder/Abstractor is involved in managing and analyzing patient information for our Level 1 and Level 3 trauma registries, Burn registry, and Acute Care Surgery registry for the purpose of research, performance improvement, injury prevention, education, billing, and outcome measurement. Data is analyzed and abstracted on all severely injured patients according to the guidelines of the University of Cincinnati Medical Center and West Chester Hospital's Trauma Registries, the American College of Surgeons Committees on Trauma and Acute Care Surgery, the American Burn Association, the Ohio Trauma Registry, and the Tri-State Trauma Coalition.


Tasks include case identification, review, and abstraction of medical data from the electronic medical record, ICD-10-CM and Abbreviated Injury Scale (AIS) coding of medical information, identification of quality improvement filters, generation of reports, data validation, and special projects as assigned.
  • Codes all injuries by assigning an ICD-10-CM diagnosis code. Scores all injuries by assigning an Abbreviated Injury Severity code based upon knowledge of rules established by the American Association for the Advancement of Automotive Medicine (AAAM). Codes all procedures by assigning an ICD-10-CM procedure code - 30%
  • Analyzes and abstracts patient data from the electronic patient record for 300+ data elements. Inputs data into the registry software program. Maintains consistency and quality of data collection for continuous quality improvement and clinical research purposes. - 30%
  • Performs monthly and ad-hoc validation of registry data to maintain consistency and quality of data collection for continuous quality improvement and research purposes. Assists in performing inter-rater reliability validation of registry data. - 15%
  • Analysis & updating of admission type and ICU accommodation reimbursement code errors in Epic. Enters appropriate registry FYI flags in Epic EMR system for billing, research, and performance improvement. - 10%
  • Daily review of expired patient reports. Properly identifies expired registry patients and obtains trauma/burn patient autopsy reports from the coroner and enters data into registry. - 5%
  • Properly identifies patients for inclusion into the trauma, burn, and acute care surgery registries. - 5%
  • Assists Trauma department staff with related registry responsibilities for continual preparation and maintenance of Level I trauma and burn verification status. Concurrent Identification of quality improvement filters. Maintains confidentiality of patient information. Performs other duties as assigned. - 5%


  • Associate degree in Health Information Management or other health-related discipline.
  • A Registered Health Information Technician (RHIT), Certified Specialist in Trauma Registry (CSTR), and/or Certified Abbreviated Injury Scale Specialist certification preferred.
  • Completion of ICD-10-CM coding course required.
  • Knowledge of medical terminology including anatomy and/or physiology.
  • Strong organizational and critical-thinking skills.
  • Strong PC skills, including strong typing skills.
  • Excellent written, verbal, and interpersonal communication skills.
  • Ability to work independently or as a member of a team.