Make a difference in people’s lives every day. When you join UCLA Health, you’ll be working at an institution that provides leading-edge care to the people of L.A. and throughout the world. We provide our team members with the environment and support to do amazing work, because each and every one of them plays a vital role in our commitment to care.
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
- 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.
- Advanced MS Office skills
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MONICA
I've been blessed to touch so many lives through my serving. It's a privilege to uplift other employees with words of encouragement and a smile.
SOZIT
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EDGAR
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RENE
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Awards & recognition
