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.

The Coder/Abstractor is responsible for ensuring that timely, accurate, and complete 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 Registry, 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 basic 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.

Responsibilities

  • 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 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. - 10%
  • Concurrent Identification of quality improvement filters. Maintains confidentiality of patient information. - 5%
  • Reviews the Expired Patient reports on a daily basis and properly identifies expired patients and enters the data into the registry. Obtains trauma and burn patient autopsy reports from the coroner and enters data into registry. - 5%
  • Performs statistical analysis of data for reporting, performance improvement, as well as, continual preparation and maintenance of Level I trauma and burn verification status. - 5%
  • Properly identifies patients for inclusion into the trauma, burn, and acute care surgery registries. - 5%
  • Participates in ongoing clinical research programs. - 5%
  • Assists the Trauma and Burn Program Managers, Medical Directors, Registry Supervisor, Performance Improvement Coordinators, and Trauma Information Coordinators with related registry responsibilities. Performs other duties as assigned. - 5%

Review the physical demands and assign an overall average percentage of time this position performs these activities. These physical demands will not be listed or rated on the annual performance appraisal. Climbing:

Ascending or descending stairs, ladders, ramps, etc, using feet and legs and /or hands and arms - 5% Stooping: Bending body downward and forward by bending spine at the waist - 5% Kneeling: Bending legs at knees to come to a rest on knee or knees - 5% Reaching: Extending hand(s) and arm(s) in any direction - 10% Standing: Remaining upright on the feet, particularly for sustained periods of time - 5% Walking: Moving about on foot to accomplish tasks - 5% Pushing 0-10 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pushing 11-20 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pushing 21-50 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5% Pushing 51 lbs or more: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pulling: Use of upper extremities to exert force in order to drag, haul or tug objects in a sustained motion - 0% Lifting 0-10 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 5% Lifting 11-20 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Lifting 21-50 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Lifting 51 lbs or more: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Carrying 0-10 lbs: Holding and moving/transporting an object about - 5% Carrying 11-20 lbs: Holding and moving/transporting an object about - 0% Carrying 21-50 lbs: Holding and moving/transporting an object about - 0% Carrying 51 lbs or more: Holding and moving/transporting an object about - 0% Fingering: Picking, pinching, typing or otherwise working primarily with fingers rather than with the whole hand or arm, as in handling - 30% Feeling: Perceiving attributes of objects such as size, shape, temperature or texture by touching with skin, particularly that of (using) fingertips - 0% Talking: Expressing or exchanging ideas by means of the spoken word - must convey detailed or spoken instructions to others accurately, loudly or quickly - 5% Hearing: Perceiving the nature of sounds at normal speaking levels with or without correction, and having the ability to receive detailed information through oral communication - 5% Seeing: The process of perceiving objects by use of the eyes to perform an activity - visual acuity requirements include ability to discern position of object(s), shape of object(s), color, depth perception or visual inspection - 30%

Qualifications

Minimum Required: Associate's degree in Health Information Management or another health-related discipline. Formal training in ICD-10-CM coding.

A Registered Health Information Technician (RHIT) and/or Certified Specialist in Trauma Registry (CSTR) certifications preferred.