POSITION SUMMARY

This position is responsible for ensuring Trauma Registry processes are in place to provide quality data in select regions and/or multiple facilities with various levels of trauma designation and/or verification that meet the requirements of the National Trauma Data Standard (NTDS), the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP), and the Arizona state (or other Banner Health state as defined) trauma rules and regulations. Operationally, this position executes system strategy across registry functions by overseeing registry team members and serving as a working leader.  This position partners with trauma service line leadership to standardize workflows, implement data quality and validation initiatives, support trauma system priorities, and coordinate regulatory readiness activities. This role ensures consistent application of National Trauma Data Standard (NTDS), American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP), and state trauma requirements while supporting trauma performance improvement, research, and trauma center designation and verification.

CORE FUNCTIONS

1. Participates in and oversees maintaining an accurate, quality-focused trauma registry database across multiple facilities and/or region(s) to ensure consistency, accuracy, and compliance, including but not limited to identification of trauma patients, data collection from multiple electronic sources and medical records, and data entry, according to the NTDS, ACS, state, and local requirements, and in conjunction with trauma registry team members, trauma data analyst, director, and executive director service line.

2. Provides leadership and direction to registry team members while overseeing standardized workflow processes and abstraction practices for maximum efficiency.

3. Participates in the design, coordination, and performance of the inter‑rater reliability (IRR) process through validation audits, and cross‑site data quality initiatives and functions to ensure data and process integrity by providing feedback on identified opportunities to team members. Involves key stakeholders, including director, executive director, data analyst, as indicated.

4. Leads onboarding and ongoing education for designated registry team members and facility stakeholders, including Trauma Program Managers (TPMs) and other trauma program team members Trauma Performance Improvement Coordinators (TPICs). Promotes professional development, competency advancement, and certification achievement to support sustained excellence in trauma data management, registry operations, and program performance.

5. Analyzes trauma data trends, identifies systemic risks, and partners with the Director to implement corrective and optimization strategies.

6. Participates in trauma registry preparation for designation and verification visits, including Pre-review Questionnaire PRQ preparation and abstraction strategy.

7. Collaborates with key team members to support dashboards, benchmarking, and reporting to create visually meaningful content related to quality metrics.

8. Serves as a subject matter expert in trauma registry standards by maintaining current knowledge and skills as pertains to trauma registry software as well as injury coding/scoring, including ICD-10 CM, E-codes, AIS scoring, and OIS scoring through active abstraction. Maintains current certifications of CSTR and CAISS once achieved. 

9. Promotes a cooperative work environment by utilizing appropriate communication skills, interpersonal relationships, and team building. Builds and supports effective relationships with internal and external stakeholders and organizations.

MINIMUM QUALIFICATIONS

Bachelor’s degree in Nursing or related field.

Must possess a current, valid RN license in the state of practice.

Current Certified Specialist in Trauma Registry (CSTR) and Certified Abbreviated Injury Scale Specialist (CAISS) certifications required.

Requires a proficiency level typically achieved with five years of clinical experience in the ED or ICU, five years of trauma registry and quality data experience and two years recent and progressive leadership experience.

Completion of ATS Trauma Registrar course within six months of hire. Completion of the most current AIS course required at the time of hire. Completion of updated ICD 10 for trauma coding within the previous 5-year period. Demonstrated multi-site operational and regulatory experience.

Experience with trauma registry software and electronic medical record (EMS) systems. Knowledge of Microsoft Office products. Strong analytical, leadership, and communication skills are essential. Demonstrated proficiency in interpersonal, written, and verbal communication, with the ability to build collaborative relationships and interact professionally and effectively with individuals, teams, and organizational stakeholders at all levels.

PREFERRED QUALIFICATIONS

Master’s degree in nursing or related field. Experience supporting ACS Level 1 or Level II trauma centers. Experience in trauma performance improvement, TQIP, leading registry validations, and designation/verification readiness. Experience in system or regional trauma programs.

Additional related education and/or experience preferred.