Clinical Documentation Specialist Level I

Lincoln Medical and Mental Health Center is one of New York City’s premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered.

Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women’s Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception.

Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

PURPOSE OF POSITION Under the supervision of the Trauma Medical Director (TMD) and the Trauma Program Manager (TPM), the lead trauma registrar coordinates daily chart input and abstraction, monitors abstracted data for accuracy of all patient data in the NYC Health + Hospitals: Lincoln Trauma Registry along with co-registrar validation.

, functions as supervisor and liaison for a team of in-house registrars, performs complex technical analysis of trauma patient data, assumes responsibility for accuracy, completeness, confidentiality and data entry of information collected, analyzes and interprets patient data to determine coding classifications including ICD-10 CM and AIS.

The lead trauma registrar will assist the trauma program manager, trauma PI coordinator and trauma medical director using the trauma registry for quality and process improvement projects and trauma-related research. The lead trauma registrar will complete all courses required by the American College of Surgeons Committee on Trauma (ACS-COT) for registrars at Level I trauma centers.

The trauma registrar will maintain clinical and statistical data, AIS and ICD-10 codes and abstract various data elements from the pre-hospital records, the electronic medical records and when applicable autopsy reports. The lead trauma registrar will assist with data protection and security and in submission of required data to the State of New York Trauma System, the National Trauma Data Bank and the Trauma Quality Improvement Program – both national and New York State.

The lead trauma registrar will report to the trauma program manager and work with the trauma team in trauma-related PI, outreach, education and research efforts. DUTIES & RESPONSIBILITIES: Data Collection Identifies patients to input into the trauma registry per trauma program inclusion/exclusion criteria. Collects and analyzes data on trauma patients that is detailed, reliable, and readily accessible; concurrent collection through chart review and staff interview if preferred.

Performs basic data collection of demographics, and coding of clinical and follow-up data from all sources into trauma registry database. Interacts with physicians, nurses, and other members of the trauma team and trauma patients to perform trauma registry functions. Keep registry current within 60 days of patient discharge.

Enters data daily into the trauma registry, analyzing patient records for data entry points as well as looking for possible quality/safety issues. Abstracts, assembles, enters, and codes clinical data with 95% accuracy into computer database by using the Association for the Advancement of Automotive Medicine Abbreviated Injury Scale (AIS), current ICD 10 coding, and all current registry users’ operations and standards manual information and NYC Health + Hospital trauma registry policies and guidelines.

Data Reporting Submits clean data (de-identified and secure) to the New York State Trauma Registry, National Trauma Data Bank and National and State Trauma Quality Improvement Programs as required and on the due dates. Produces reports from trauma database in Microsoft Word, Excel or PowerPoint as requested by trauma staff after approval by the trauma medical director and if applicable for research the IRB.

Participates in quality assurance and improvement activities to ensure accuracy of data collection and timely submission of data according to trauma center and external verification and certification agencies. Data Validation Participates in process of validation of registry data. Data Security/Patient Confidentiality Maintains patient confidentiality including confidentiality of sensitive hospital performance improvement information.

Other Resolves routine coding issues/problems and appropriately seeks assistance from trauma registry vendor staff for the more difficult issues. Participates in trauma process improvement and ACS-COT required committee meetings and educational conferences in order to maintain and expand trauma registry knowledge base.

Identify opportunities for process improvements and provide analysis and propose change and communicate strategies Participates in internal and community outreach education on injury prevention, trauma systems, and trauma data. Provide supervision and guidance to junior registrars, consultants, and/or other appropriate project team members Participates professionally in hospital committee meetings, clinical meetings, and rounding related to trauma care.

Assists with other departmental functions as assigned including preparing for verification assessment by the ACS-COT every three years. Lead the training, development and implementation of process improvements for all projects and applications along with the TPM and trauma PI Coordinator. Maintains mandated educational requirements as described by the American College of Surgeons standards for trauma designation.

Maintains knowledge of registry requirements and coding not limited to ICD-10, ISS, AIS and TQIP through collaboration with peers, vendor, and regulatory agencies by attending conferences, webinars or conference calls. Performs all other related tasks as defined and assigned by the Trauma Medical Director and the Trauma Program Manager.

1.Valid New York State license and current registration to practice as a Registered Professional Nurse(RN) issued by the New York State Education Department (NYSED); and Bachelor of Science in. Nursing degree from an accredited college or university; and four (4) years of acute care experience;or 2.Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issuedby the NYSED; and two (2) years of experience, as described in “1” above; or 3.

Valid New York State license and current registration to practice as a Physician Assistant (PA)issued by the NYSED; and two (2) years of experience, as described in “1” above; or 4.Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or 5.Successful completion of education that leads to a medical degree; and two (2) years of experience,as described in “4” above.

The American Trauma Society’s Trauma Registry Course or equivalent provided by a state trauma program. The Association of the Advancement of Automotive Medicine’s Injury Scaling Course. Certified Abbreviated Injury Scale Specialist (CAISS) certification

NYC Health and Hospitals offers a competitive benefits package that includes: Comprehensive Health Benefits for employees hired to work 20+ hrs. per week Retirement Savings and Pension Plans Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts Loan Forgiveness Programs for eligible employees College tuition discounts and professional development opportunities College Savings Program Union Benefits for eligible titles Multiple employee discounts programs Commuter Benefits Programs

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