Performance/Quality Improvement Nurse (Trauma Dept.)
Job Summary Involves the establishment and supervision of processes (e.g., performance improvement, clinical documentation, etc.) to achieve the optimal degree of excellence in the services rendered to every trauma patient. Evaluation of practice operates within the parameters of patient outcome, cost-benefit in care provision, and patient access to the health care delivery system. Provides for internal strategic planning efforts and implements continuous quality improvement programs.
The Performance Improvement Specialist is actively engaged in PI evaluation, review, and solution generation/implementation to improve the optimal care of the trauma patient. The Clinical Registrar & PI Specialist is skilled in writing reports and presenting data graphically, both internally and externally, to promote process improvements, improved outcomes, and optimal patient care.
Additionally trained in Trauma Registry, the clinical trauma registrar is responsible for maintaining and assuring the quality and accuracy of the trauma registry database, the foundation of the trauma PIPS process. This role contributes to the development of standard work and, during the process of trauma registry data entry, reliably identifies cases that warrant review, fully completes data abstraction into the trauma registry database according to Trauma Service standards, trauma leadership needs, existing regulatory requirements, and meets data entry deadlines for the County, NTDB, and TQIP. The Registrar collects, analyzes, and reports trauma data for quality improvement tracking as assigned, as well as targeting injury research and prevention. This role implements processes to ensure accuracy and confidentiality in the handling of all trauma registry-related matters. The final salary and offer components are subject to additional approvals based on UC policy. Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement. The salary range for this position is $100,300 - $150,500 (Annual Rate). To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html Department Description The BHC Oakland Trauma Program supports and sustains the hospital's designation as a Level I Pediatric Trauma Center, verified by the American College of Surgeons (ACS). The program ensures compliance with ACS standards, facilitates trauma center verification, and contributes to national trauma registries to benchmark performance, support research, and drive system-wide improvement.
Key responsibilities include trauma registry management, data analysis and reporting, performance improvement coordination, and oversight of injury prevention and community outreach initiatives. The program collaborates closely with hospital leadership, clinical departments, the ACS, and regional EMS authorities to advance trauma care quality and promote public health and safety. Required Qualifications
- Minimum 3 years of experience working as a Registered Nurse in a critical care environment required.
- Demonstrates breadth and/or depth of knowledge and skills required for the position, including a proficient understanding of pathophysiology and medical terminology.
- Maintains current knowledge with national and regional trauma registry requirements and practices; shares technical knowledge. This includes required clinical and database knowledge and skills, as applicable.
- Basic knowledge of ICD-9/10 coding.
- Demonstrated ability with databases, including data entry, data abstraction, and data validation.
- Ability to utilize data from computer-based and paper-based sources to generate reports.
- Demonstrated knowledge of Alameda County EMS-A trauma center designation criteria.
- Demonstrated knowledge of ACS verification requirements.
- Demonstrates integrity, honesty and dependability to solve a variety of problems.
- Demonstrates good judgment and a practical decision-making process to solve problems and set appropriate priorities, including delegation of tasks, while being inclusive to inform/seek input from all key stakeholders regarding any quality improvement initiative.
- Actively seeks out current evidence and resources for assistance and direction to facilitate improvement in identified clinical care; this includes networking with internal and external resources (i.e. TQIP).
- Appropriately seeks to clarify role expectations, hospital policies and procedures, and appropriate interventions.
- Promptly solves problems and resolves complaints.
- Ability to abstract and review data for clinical compliance with unit and organizational standards.
- Knowledge of guest relations and hospital and unit resources. Applies this knowledge to contribute to the smooth transfer of information.
- Trauma Registrar certification (CSTR); must be completed within one year of hire.
Preferred Qualifications
- Knowledge of Structure Standards, Procedures, Protocols, Guidelines as needed to perform job functions
- Ability to organize and prioritize tasks
- Minimum 2 years of experience with Medical Records and ICD 9/10 coding experience preferred.
- Experience with Abbreviated Injury Scoring (AIS), Injury Severity Scoring (ISS) Trauma Registry preferred; preferably experience with Lancet Trauma One Registry. ICD -10 coding training preferred.
- Demonstrated knowledge to report data based on requested queries.
- BSN strongly preferred
- AAAM Coding Course completion and/or American Trauma Society Registrar Basic and/or advanced course completion (may complete within 1 year of hire).
- Certified Coding Specialist (CCS) certification preferred
License/Certification
- Associate Degree
- Currently licensed in California as a Registered Nurse
- BLS Required
- Trauma Registrar certification (CSTR); must be completed within one year of hire.
- College level anatomy/physiology and pathophysiology course completion and/or equivalent
- clinical work experience required.
About UCSF At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team.
Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents. Pride Values UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as our PRIDE values.
In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at diversity.ucsf.edu
Join us to find a rewarding career contributing to improving healthcare worldwide. Equal Employment Opportunity The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law. Job Code and Payroll Title 004204 QLTY IMPV HC SPEC 3 Job Category Nursing - Adult Critical Care, Nursing - Adult Services, Nursing - Training Programs/Internships, Other Nursing Bargaining Unit 99 - Policy-Covered (No Bargaining Unit) Campus Benioff Children's Hospital Additional Shift Details Monday-Friday |
University of California - San Francisco Campus and Health
Sep 16, 2025