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Skills
Analysis Skillsunmatched
Anatomyunmatched
Benchmarkingunmatched
Cancerunmatched
Clinical Dataunmatched
Clinical Informationunmatched
Clinical Study Publicationsunmatched
Communication Skillsunmatched
Computer Skillsunmatched
Data Entryunmatched
Data Qualityunmatched
Diseaseunmatched
Documentationunmatched
Electronic Medical Recordsunmatched
English Languageunmatched
Establish Prioritiesunmatched
File Maintenanceunmatched
Health Informaticsunmatched
Hospitalunmatched
International Classification of Diseases (ICD)unmatched
Medical Codingunmatched
Medical Recordsunmatched
Medical Terminologyunmatched
Microsoft Officeunmatched
Organizational Skillsunmatched
Pathologyunmatched
Patient Careunmatched
Patient Confidentialityunmatched
Presentation/Verbal Skillsunmatched
Public Healthunmatched
Quality Metricsunmatched
Regulationsunmatched
Regulatory Complianceunmatched
Surveillanceunmatched
Time Managementunmatched
Writing Skillsunmatched
Description
Job Description
Description
The Patient Record Abstractor IV is responsible for accurately abstracting and coding clinical information from cancer patient medical records in accordance with the standards of the California Cancer Registry (CCR), SEER Program, California Cancer Surveillance Program (CSP), UCLA Cancer Registry, and the Commission on Cancer.
This position supports UCLA Health’s commitment to data integrity, regulatory compliance, and cancer surveillance, contributing to improved patient outcomes, research, and public health reporting.
Key Responsibilities
Cancer Data Abstraction & Coding
Abstract and code clinical and pathological data from medical records using CCR, SEER, CSP, and Commission on Cancer guidelines
Assign ICD-O codes, accession/sequence numbers, and ensure accurate data entry into the cancer registry database
Staging & Classification
Determine and assign appropriate:
SEER Summary Stage
TNM staging for analytic cases
Extent of Disease (EOD)
Medical Record Review
Review and analyze patient information in the electronic medical record (CareConnect) and paper charts as needed
Validate clinical documentation to ensure completeness and accuracy of abstracted data
Treatment & Case Completion
Abstract all required treatment information to ensure complete and timely case reporting
Ensure all reportable cases are finalized in compliance with registry standards
Quality & Productivity
Maintain a high level of accuracy (≤3% error rate) in accordance with CCR standards
Meet or exceed established productivity benchmarks
Salary Range: $41.7 - $55.03 hourly
Qualifications
ODS certification required
5+ years abstracting experience
Experience using CNEXT, EPIC, and MS Office software (Constant)
Experience using computer equipment (Constant)
Experience using internet to locate sites and information needed for cancer reporting (Constant)
Must meet productivity standards and State quality standards
Detailed knowledge of the American College of Surgeon standards, California Cancer Registry and SEER standards.
Detailed knowledge of medical terminology, anatomy, pathology, and disease processes.
Detailed knowledge of ICD-0 coding classification scheme
Ability to abstract clinical information from patient records and code data accurately into Cancer Registry database and follow-up if additional information is needed.
Excellent organizational skills in maintaining Cancer Data files.
Skill in prioritizing and performing a variety of duties within a system that has constantly changing priorities, assignments, and deadlines.
Detailed knowledge of laws, rules and regulations affecting the confidentiality of medical information.
Skill in working independently and following through on assignments in an environment with frequent interruptions.
Skill in writing legibly and in using basic English words to complete concise documentation.
Knowledge and understanding of functions and activities of various hospital departments contacted for source information to expeditiously coordinate follow up procedures.
Ability to work independently and exercise appropriate decisions in determining follow up actions and complete assignments in a timely manner.
Ability to judge system/procedure malfunction/discrepancies and circumstances to be referred to supervisor for immediate action.
Strong oral and written communication skills for the purposes of conveying information to individuals at various organizational levels and the general public and in completing concise documentation.