Thrive Health Care Services

Trauma Abstractor

Posted on

March 22, 2025

Job Type

Contract

Role Type

License

RN

State License

Virginia

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Company Description

Job Description

100% Remote Work JOB TITLE: Data Abstractor I Fully Remote - except NY, CO, and CA Flexible hours as long as they are available for training during normal business hours.

Requirements

EDUCATION REQUIRED: High school degree (or equivalent) required. PREFERRED: Undergraduate (Associates or Bachelor) degree or successful completion of a certified coding program EXPERIENCE: 1 year in Health Information Management; Coding or Health Registry abstraction experience preferred PREFERRED: RHIA, RHIT, CSS, LVN or RN 2+ years’ experience as a Trauma Registrar/Abstractor required ICD 10 data abstractor system experience required Trauma Registry Course required AIS 15 Course required 2+ years of experience with Level 1 or 2 Trauma Centers (Certified in CSTR or CAISS strong plus) Certified in CSTR or CAISS (strong plus) EMR/Registries in DI or CDM (trauma) Meditech Expanse or Epic or Cerner EMR experience KNOWLEDGE, SKILLS & ABILITIES: Familiar with medical record documentation Basic medical terminology and physiology Able to navigate through the medical record and locate specific documentation Understanding of patient discharge disposition and where to validate in the medical record Ability to extract data from medical record content for abstraction Proficiency in computer skills to include Microsoft Office applications Possess basic keyboard skills Knowledge of medical terminology, quality measures and coding logic.

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Responsibilities

This position is responsible for abstraction of data for core measure, trauma, VON and/or various cardiovascular services. SUPERVISOR: Manager, Clinical Data Abstraction DUTIES INCLUDE BUT ARE NOT LIMITED TO: Completes abstraction process for assigned facility(ies), including abstraction of cases into the required system (e.g., COMET, TheraDoc, Digital Innovations, NHSN, etc.). Responsible for reviewing medical records to abstract information according to the standards of various regulatory and accreditation agencies (e.g., CMS, TJC, NHSN, etc.). Performs timely abstraction to ensure compliance with standards. Completes edit checks and makes appropriate changes on a timely basis. Follow standards and CSG/Parallon nstructions to abstract all reportable cases. Assist with case follow-up as requested. Attend educational activities as approved by Manager and/or Director. Maintain clinical knowledge of various abstracted measures. Communicate in a timely manner with manager to achieve measure compliance. Submit data timely through the appropriate reporting system. Resolve errors resulting in the rejection of records from the data entry system. Participates in required continuing education programs and annual reorientation. Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement” Other duties as assigned

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