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Summary

Job Description

POSITION SUMMARY: Responsible for complete and accurate review of all trauma patient records, collecting data for the PA Trauma Systems Foundation (PTSF), trauma services medical record abstract, and decision support in managing the care of the trauma patient. Maintains and protects the integrity of the Trauma Registry database including S.M.S. and Collectorä interfaces, data management, data analysis, report writing, as well as statistical and graphic output of trauma data.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

• Performs concurrent in-house trauma record abstraction and interprets the clinical data in the record for accurate entry into the trauma database in a timely manner. Generates and analyzes concurrent data reports in response to Trauma Service requests or through self-directed processes. Maintains confidentiality and security of all patient data in the Trauma Registry.

• Accurately assigns applicable ICD-9-CM codes for all injury descriptors and procedures found in the trauma patient medical record. Determines optimal AIS score for injuries. Effective utilization of the ICD-9-CM coding books, Tricodeä software, Abbreviated Injury_Scale scoring book by the Association for the Advancement of Automotive Medicine, and encoder are essential. Conforms to PTSF requirements for Accredited Trauma Center participation in the state registry.

• Actively participates as a vital team member in concurrent and retrospective Trauma Service performance improvement initiatives by providing expertise with data retrieval and data manipulation from the trauma registry system. Analyzes data and provides information ensuring that customer requirements are met by utilizing reports and graphics.

• Acts as system administrator for the Trauma Registry. Assures the integrity of the system with timely updates, enhancements, and system back-up. Is able to independently troubleshoot hardware and software system problems as they arise.

• Concurrently analyzes patient medical records according to established criteria to identify patients for inclusion in the Trauma Registry database. Accurately and efficiently identifies PTSF qualifiers and audit filters and assures timely submission of data via the electronic bulletin board system to the PA Trauma Systems Foundation. Maintains an accurate trauma patient log.

• Functions as an important resource to plan, identify, trend, analyze, and integrate new data collection elements for use in trauma patient care management, performance improvement, statistical and research purposes. Proficient in report writing skills while utilizing trauma registry data.

• Attends and actively participates in required PTSF and hospital education sessions. Participates on trauma-related committees. Demonstrates communication skills that support the registrar’s role in trauma initiatives.

• Participates in registrar inter-rater reliability reviews.

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

• Completes a statistical report of all trauma patient and registry data and prepares a monthly report to Trauma Administration.

• Prepares pull lists for special studies and audits.

• Assists and actively participates in site survey process.

• Assists in research projects in tandem with the Trauma Services team.

JOB REQUIREMENTS

MINIMUM REQUIRED QUALIFICATIONS:

• High School diploma or equivalent.

• Two (2) years experience as an Allied Health professional is essential.

• Working knowledge of ICD-9-CM and personal computer is essential.

• Typing skills and statistical abilities are essential.

PREFERRED QUALIFICATIONS:

• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT) or Registered Nurse (RN) or completion of certificate/degree in Allied Health profession is preferred.

• Knowledge of quality care audit procedures is preferred.

COGNITIVE REQUIREMENTS

ATTENTION/CONCENTRATION – The following level of ability is essential for the jobholder to focus on certain aspects of current experience and reject others:

• The position requires the ability to attend to more than one aspect of a situation simultaneously. It is highly likely that multiple task demands are going to be required of the individual at the same time.

NEW LEARNING AND MEMORY – The following level of ability is essential for the jobholder to learn and retain material:

• A large portion of this position required reliance on verbal memory and new learning. Efficiency in processing of verbal information, either in written or spoken form, is a major requirement and prerequisite of the job. The individual must be able to attend to and process multiple bits of information simultaneously. The individual must be able to organize and categorize this information effectively so that later recall is feasible.

PROBLEM SOLVING, REASONING AND CREATIVE THINKING – The following level of ability that is essential for the jobholder to think (in order to solve a problem) by combining two or more elements from past experience or imaginative thought:

• The position required much autonomy of thought and problem solving. The individual must be able to apply principles of logical or scientific thinking to define problems. The individual must be able to think abstractly, which is manifested in the ability to form concepts, use categories, generalize from single instances, apply procedural rules and general principles, and be aware of subtle or intrinsic aspects of a problem. The development of hypothesis and potential solutions to problems involves careful interpretation, analysis and diagnosis. The individual must be able to collect data, establish facts, and draw valid conclusions. The individual must be able to think creatively with a degree of inventiveness, experimentation and intuition. They must be able to deal with a variety of concrete and abstract variables.

TEMPERAMENTS: The following are essential requirements of the position in relation to job-worker situations. These items describe how a worker must adapt, adjust, conform or act:

Creativity, feelings or ideas: Ability to adapt to situations involving the interpretation of feelings, ideas, or facts in terms of personal viewpoint; to use creativity, self-expression, or imagination.

Working within tolerances, set limits or standards: Ability to adapt to situations requiring the precise attainment of set limits, tolerances, or standards; to be precise, thorough, exacting, or meticulous in regard to material worked; or in activities such as numerical determinations, record preparation, or inspecting.

Variety and change: Ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure involving significant differences in technologies, techniques, procedures, environmental factors, physical demands, or work situations.

Communication: Ability to exchange information with others clearly and concisely; to present ideas, facts and technical information.

Planning and control: Ability to identify task requirements and monitor progress toward accomplishment.

Interpersonal relations: Ability to maintain relationships that facilitate task accomplishment; to cooperate and resolve conflicts; to recognize needs and be sensitive of others.

EQUIPMENT USAGE REQUIREMENTS

Equipment/Tools: computer, printer, copier, telephone, office supplies.

Software: clinical information system, word processing, spreadsheet, database

PHYSICAL REQUIREMENTS

Rarely 0-10%; Occasionally 11-35%; Frequently 36-70%; Continuously 71-100%

Body Position/Movement:

• Sit: Continuously

• Stand: Rarely

• Walk: Occasionally

• Bend: Rarely

• Push: Rarely

• Pull: Rarely

• Kneel/Squat: Rarely

• Reach: Rarely

• Twist: Rarely

• Balance: Rarely

• Climb: Rarely

Lifting: Degree of physical exertion is :

Light , exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to move objects.

Sensory Abilities specifically required:

• Vision

• Hearing

PHYSICAL ENVIRONMENT

WORKING CONDITIONS: Exposure to hazardous conditions/ materials is negligible.

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards. The percentages of time spent performing job duties are estimates, and should not be considered absolute. The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole. Incumbent must be able to perform all job functions safely.

Benefits At A Glance:

PENN MEDICINE LANCASTER GENERAL HEALTH offers the following benefits to employees:

• 100% Tuition Assistance at The Pennsylvania College of Health Sciences

• Paid Time Off and Paid Holidays

• Shift, Weekend and On-Call Differentials

• Health, Dental and Vision Coverage

• Short-Term and Long-Term Disability

• Retirement Savings Account with Company Matching

• Child Care Subsidies

• Onsite Gym and Fitness Classes

Disclaimer

PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.

Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.

PENN MEDICINE LANCASTER GENERAL HEALTH, a member of the University of Pennsylvania Health System (Penn Medicine), is a not-for-profit health system with a comprehensive network of care encompassing Lancaster General Hospital (LGH), Women & Babies Hospital and the Lancaster Rehabilitation Hospital (a partnership with Kindred Healthcare). We are an Accredited Trauma Center-Level I through the Pennsylvania Trauma Systems Foundation with 805 Licensed beds. Our membership in Penn Medicine brings together the strengths of a world-renowned, not-for-profit academic medical center and a nationally recognized, not-for-profit community healthcare system.

Outpatient services are provided at the Downtown Outpatient and Suburban Outpatient Pavilions, along with additional outpatient centers and Express and Urgent Care locations throughout the region. Lancaster General Health Physicians is a network of more than 300 primary-care and specialty physicians, at more than 40 offices throughout the region.