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Job Description

**Job Title:** Trauma Registry Performance Improvement Coordinator

Works in collaboration with trauma program leadership to improve the quality of trauma care encompassing all areas and disciplines of the hospital that participate in the management of the injured patient. Responsible for coordination and facilitation of the division performance improvement program; including data collection, analysis, trending and benchmarking of data and outcomes. Has primary responsibility for trauma registry data collection; core elements include data entry, database management, data validation, injury coding and scoring, statistical data analysis; report design; supporting administrative, outreach, injury prevention and research initiatives. Collaborates closely with trauma program leadership to ensure compliance with the State of New York trauma regulations, American College of Surgeons standards, facility standards related to Performance Improvement.

Qualifications

_Requirements:_

+ AS/AD required; BS or BSN preferred. Degree in health-related discipline preferred

+ ICD-10-CM/PCS coding certification, AIS 2015 coding certification

+ Certified Abbreviated Injury Scale Specialist (CAISS) or required within 12 months of employment

+ Certification in Trauma Registry or required within 24 months of employment.

+ 3-5 years of position related experience defined as Medical Records, coding experience, trauma Outreach experience, Trauma Program experience, performance improvement experience.

Compensation Statement

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $58,661.00 - $.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Non-Bargaining Unit, BPL - Surgery Trauma Program - STL, Mount Sinai St. Luke's

Responsibilities

**Trauma Program Leadership** :

+ Implement and sustain integrated Division Performance Improvement plan that meets all regulatory requirements.

+ Facilitates identification, validation, and documentation of department- based,

+ Hospital-based, State of New York and selected American College of Surgeons Performance improvement variances and complications.

+ Performs comprehensive, concurrent chart review to identify quality, timeliness and system issues in the care of patients, in order to meet facility needs, State of New York needs, and American College of Surgeon’s standards.

+ Assures collection/inclusion of data in relevant databases to allow ongoing evaluation of program performance improvement initiatives.

+ Assists the Trauma Program in the development of both clinical and operational performance indicators, supports an integrated program for trauma peer review morbidity and mortality review, outcomes analysis and reporting.

+ Attends trauma related meetings and prepares peer review cases for appropriate venue.

+ Effectively facilitates and/or leads team in divisional/hospital approved continuous quality improvement methodology.

+ Maintains knowledge of and participates on hospital committees and initiatives related to quality.

+ Maintains secure and confidential documentation of all PI activities, including patient performance improvement files, minutes of peer review and process improvement meetings using standard format.

+ Maintains case review summaries and a tracking system for trends/follow-up and updates concurrently.

Registry** **Maintenance:

+ Accurately abstracts comprehensive trauma patient information from multiple sources and maintains registry, with data abstracted and entered into the registry in as close to concurrently as possible as and no later than 60 days post-discharge.

+ Facilitates optimal data abstraction by maintaining knowledge of data sources, especially in the developing electronic medical record.

+ Customizes/creates data fields to optimize efficiency and utilization of registry.

+ Oversees the appropriate and standardized performance improvement data fields used to meet the needs of the program and to maintain compliance with any regulatory agency or benchmark organization identified by the program.

+ Demonstrates/verifies proficient use of the current ICD coding and the AIS and ISS injury scoring systems.

+ Creates/upholds administrative procedures for the Trauma Registry.

+ Serves as a resource/mentor to others in the area of trauma registry/performance improvement.

**Data Reporting** :

+ Proficient in data analysis of trauma program studies, including clinical, quality,

+ Administrative, epidemiologic, research, and prevention.

+ Designs reports that accurately represent information in the context provided.

+ Through the use of trauma registry, peer review information, and other relevant databases, provides a standardized set of analytical, statistical and reporting strategies for a variety of patients or provider outcomes, to be reviewed by internal and external review committees.

Other Assigned Duties:

+ Facilitate the development of and/or creation of clinical management guideline surveillance, variance, and reporting in conjunction with trauma program leadership.

+ Establish channels of communication and reporting which encourage interdisciplinary cooperation, respect, and support among members of the trauma service and the personnel with which they come in contact.

+ Participates in local, regional, state, and national organizations to expand knowledge and program development.

+ Assists with maintaining trauma policies and procedures.

+ Assists with preparation for regulatory agency surveys.

+ Demonstrates advanced computer skills in database management, spreadsheet and word processing applications.

+ Demonstrates good judgment, problem solving abilities, and effective communication skills using a multidisciplinary approach.

+ Able to organize and prioritize multiple tasks and projects.

+ Able to maintain confidentiality of patient, provider, and organization information.

+ Assist trauma staff in other assigned duties as requested.

About Us

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation Statement

Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $58661 - $67500 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.