Trauma Registrar 40 Hr Wk 61431 Year resume example

• As Certified Professional Coder with 5 years of experience in Department of Defense Trauma Registry, I am an expert in coding and data entry into the DoDTR.
• I insured implementation of Department of Defense Trauma Registry (DoDTR) including rules and regulations related to submission of data to the trauma registry.
• Proficient in abstracting data from multiple sources while improving consolidated records analysis.
• I achieved goals of the Trauma Program which promoted optimal care to the combat casualty and embraced LRMC priorities.
• I owned the knowledge of trauma related diagnosis ICD9 and ICD 10 coding and procedures CPT/PCS coding, as well as Abbreviated Injury Scoring (AIS) and Military Injury Severity Scoring (MISS).
• I utilize all skills and knowledge to register, code, manage, analyze and review Department of Defense Trauma Registry (DoDTR) for all local and downrange trauma inpatients medical records to ensure accuracy, internal consistency and correlation of recorded-data required by the Joint Commission-Standards for Hospitals.
• Utilized ICD-9 Volume I, II and III codes and Military Abbreviation Injury Sale (AIS) codes for accurate coding of complex medical records that involve difficult to classify injuries (i.e.
• Burn injuries, cardiothoracic surgery, new diseases, treatments, etc.) I am proficient in the medical terminology, anatomy, and coding of all diagnosis and procedures of the trauma inpatients.
• I collected all necessary data elements to prepare Trauma Registry Daily Census for all trauma patients.
• I verified patient’s demographics in DEERS.
• I scanned all local, downrange and Landstuhl Regional Medical Center (LRMC) documentations to Medshare automated shared folders and make sure that all documents are available for abstraction.
• I abstracted and performed data entry into the Department of Defense Trauma registry (DoDTR).
• After patients’ discharge, I uploaded all inpatient discharge summaries to TMDS and other documents upon request.
• I use S.A.F.E to request and pick up encrypted autopsy reports as needed.
• I utilized Report Writer to run all reports and ensured completeness of those reports including designing, creating, and reformatting that require advanced functions to generate statistical data that describe the injury event demographics, diagnosis, and outcomes.
• I prepared and updated numerous weekly and monthly spreadsheets, regular and pivot point charts and graphs using Microsoft Excel.
• Collected concurrent, comprehensive data on all trauma admission, trauma transfers in and out of LRMC.
• Ran reports in JTTRv3 to support registry, ensure registry data is composed of uniform data elements that describe the injury event demographics, diagnosis care, and outcomes.
• Ensured the use of validation to help detect errors and ensuring that the data entered is accurate.
• Analyzed medical records and make sure that all data entry completion and, medical diagnosis/procedure accuracy is available through numerous of reports utilizing excellent informatics skills and knowledge of different software packages.
• Demonstrated appropriate time management skills for registry, coding, and numerous of daily, weekly and monthly reports.
• Responsible for data entry into Department of Defense Trauma Registry (DoDTR), Trauma Workflow, Monthly Inpatient Registry data tracking, data file maintenance, ACS verification.
• Monitored speed issues and report identified database problems to ISR in San Antonio for technical support.
• Managed collection maintenance and consolidation of data.
• Have ability to summarize data and identify inaccuracies, which able to fix, plan and organize.
• Communicated with personnel within medical record and research section for the purpose of exchanging and clarifying information about medical records.
• I am compliant with LRMC Trauma Program and Institute of Surgical Research (ISR) rules and regulations.
• Consistently clarified information about medical records and need of diagnosis specificity to ensure appropriate AIS code is assigned to generate accurate ISS score.
• Consistently liaison TNC’s with changes that may come from ISR and ICD 9 annual changes and transition to upcoming ICD 10 coding use.
• Assist in medical care evaluation studies.
• I was extensively involved with the preparation for The American College of Surgeons Level I, and Level III Trauma Verification process.
• Trained and assisted staff with multiple data source programs.
• Due to downsizing of the department with the skills in time managing, I performed all Administrative Assistant and Informatics Coordinator duties.
• Organized Trauma Program MedShare Information storage site to easier locate necessary files and folders and comply with HIPPA regulations.
• I was Point of Contact for access to MedShare and Department of Defense Trauma Registry, Report Writer, and other electronic access needs for LRMC trauma department.
• I independently planned workload, resolved problems and made adjustments in accordance with LRMC standard operating procedures.
• Continuously trained new staff and updated current staff in the department with the new DoDTR database system, Report Writer, Microsoft Word, Power Point, Microsoft Excel, Medshare, Trauma Registry Database Dictionary, etc.
• Accessed patient information through variety of office software applications, maintaining strict confidentiality to remain compliant with HIPAA regulations.
• Compiled physical and digital documents, charts and reports to meet business and patient need.

I had six years of direct patient care as Clinical Medical Assistant in outpatient ambulatory setting, concerning patient’s lower extremity with supervisory responsibilities. Obtained and provided patient general and podiatry medical history, allergies, current medication and drug sensitivities to the physician taking care of the patient for that day. I performed vital signs check and drew pre-operative blood work, recorded vital signs and allergies in patient’s hard copy and electronic medical record.
I also utilized my administrative duties, such as analyze inpatient medical records to insure accuracy, efficiency according to rules required. I maintained medical records storage room ensuring HIPPA compliance. I documented data precisely and correctly into patient’s electronic and hard copy medical record. Analyzed codes, receiving medical records requests, and released records after review, passed records to a medical coder. I prepared necessary paperwork for medical records requests for patients, insurance, disability insurance companies, workers compensation and litigation cases. I screened mail and informed medical providers of any requests. I collected required payments, and submitted all requested records on case by case basis.
Suggested procedures to general manager for reducing technician clinical time from 45 minutes to 20 minutes to prepare and accomplish assigned tasks. Filed documents and reviewed requests from physicians, and other health care providers for procedures and examination to be conducted on proper patient examination to provide physician with technical information. I trained all new clinical staff of how to promptly and efficiently perform both clinical and administrative duties without delay. I worked closely with general manager on medical records submission and reported any difficulties finding old files. I monitored medical records electronic log, to assure that all of the requests were completed promptly and on timely manner.
As a circulator on surgery days, I counted all of the necessary items, and matched them with appropriate codes on the surgical router. Then they would be reviewed by surgeon. I created letters of medical necessity for various implants, soft goods, medications, per physicians order. I electronically entered ICD-9 codes and CPT codes into Quest Diagnostic Care 360. I completed requisition slips, and processed blood and tissue specimens in a timely fashion. I performed venipuncture, and urinalysis.
I worked as surgical scrub technician, prepared operating room for all procedures related to the foot and ankle surgeries. As recovery room technician, I observed patient’s for safety during the transport to radiology section, and back, assisted physician with patient. Provided discharge paperwork and verbal post-operative instructions. Assisted and administered appropriate medication per physician’s orders. I processed all digital X-Rays of the lower extremities. Casted patients and performed routine nail and lesion debridement, followed by independently completing routers with ICD-9 and CPT codes, which then were later sent to billing department. I sterilized instruments, maintained a clean utility room, and ordered supplies. Supported anesthesia team by stocking necessary supplies, and. Called in prescriptions, returned patients phone calls, made appointments, scheduled surgeries, helped check in and out office as needed, Used Medinotes, Microsoft Excel to keep inventory and budget log, Appointment Pro, Quest Diagnostic Care 360, Medisoft, Data Base, Onyx.

As clinical Medical Assistant, I escorted patients to the treatment room and obtained brief patient medical history and documented in medical record. I assisted both the physician and physician assistant with the following procedures: Liposuctions, Scalp Reductions, Hair Transplants, Laser Hair Removals, Fat Transplants and harvesting, Botox, Restylane, Juviderm, Sclerotherapy, Laser Tattoo removals, Thermage. I resupplied treatment rooms, filed medical records, processed specimen collection, and informed the clinic of the latest medical technology after interacting with medical sales representatives. Also, provided education to patients regarding their treatment plan and maintained HIPPA compliance