Job Description

Job Title: Trauma Registrar (HIM/Coding)
Job ID: 771625
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Presbyterian
Department: Trauma Service
Location: 1515 Locust Street, Pittsburgh PA 15219


Grow in your registry experience!  We are looking for a Trauma Registrar to join our Trauma Registrar team.  This role will maintain the efficient operation of the Trauma Patient Registry and ensure consistency and quality in the data collection system.  The registrar is responsible for the identification of trauma patient, admissions, abstracting, coding and entering information into the trauma database. They will utilize the retrieval of data for quality assurance purposes. They must comply with Pennsylvania Trauma Systems Foundation requests for data.  They will also work closely with the Trauma QA/Registry Coordinator and Trauma Program Manager. They will also interact with Medical Records, Information Services personnel, and patient unit staff.

This role is full time, Monday through Friday during daylight hours. 

  • Abstract from the trauma patient medical record relevant information required for the hospital registry and the Pennsylvania Trauma Outcome Study, including selection and coding of diagnoses and procedures using ICD10-CM, and calculation of trauma and Injury Severity Scores accurately and efficiently.
  • Accurately maintain the computerized registry system, which includes keying data, making additions, and making corrections as necessary.
  • Attend and participate in Trauma QI activities such as MAC meetings.
  • Conduct concurrent review of trauma patient records within 48 hours of admission and enter select information into the database to provide current information for quality assurance, outreach, education, and public relations purposes.
  • Contact appropriately the Trauma QA/Registry Coordinator for problem solving and clarification of clinical information.
  • Demonstrate an awareness of the hospital's commitment to provide excellence in trauma patient care by supporting the Trauma Program's service management objectives.
  • Document and disseminate information as appropriate.
  • Document data and time of attendance at continuing education programs.
  • Engage in follow-up activity as appropriate
  • Ensure that all PTOS information is accurate, complete, and submitted within the time frames established by PTOS protocol.
  • Follow protocol for removing or adding patients to the database.
  • Identify appropriately trauma patients by monitoring on a daily basis the Emergency Department and Admitting Department identification systems.
  • Maintain accurately the statistical database, generate routine monthly reports, and respond to special requests for statistical information.
  • Maintain and expand current knowledge base through attendance at appropriate in-services or seminars and by studying reference material.
  • Maintain communications with the state Trauma Registrar and/or PTOS analysts for purposes of clarifying information or respond to requests for clarification of information.
  • Maintain confidentiality of patient information and follow hospital policies relating to security of patient information.
  • Perform additional trauma patient medical record abstracting or audit activities for quality assurance, research, education, or for the purpose of identifying and addressing documentation deficiencies.
  • Perform related responsibilities as requested by the Trauma Program Manager.
  • Retrieve information from the database upon request of Trauma Services or other appropriate personnel. Determine the data elements and design the output for the request.
  • Work with the Trauma Nurse Specialist and Trauma QA/Registry Coordinator to collect, organize, and disseminate results.


  • High School Diploma with a minimum of three years of trauma registry, coding and/or abstracting experience OR a Graduate of an accredited record technician program or an Associate Degree with one year of trauma registry, coding and/or abstracting experience  
  • Require to demonstrate knowledge of medical record content, medical terminology, anatomy and physiology. 
  • Require prior experience in ICD-10 coding.  
  • Desire abbreviated Injury Scoring (AIS). 
  • Demonstrate experience in computer data entry, databases, and data retrieval is desirable

Licensure, Certifications, and Clearances:
  • Act 34 Criminal Clearance

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $15.58 to $24.54 / hour

Union Position: No

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