Patient Records Abstractor 4

Job Overview

This role demands advanced expertise in areas such as clinical coding, data handling, medical billing systems, and familiarity with governmental programs. The primary objective is to accurately identify, abstract, and report malignant cases for the UCSF Medical Center Cancer Registry by analyzing various medical documents and electronic records. The information is abstracted and coded following specified formats to comply with state and national cancer registry standards including the California Cancer Registry (CCR), Commission on Cancer, and the Surveillance, Epidemiology, and End Results (SEER) program. In addition, the abstractor maintains tracking and quality control systems and coordinates quality control projects within the department. Oncology treatment protocols and registration guidelines form the knowledge foundation for this role. A Certified Tumor Registrar (CTR) certification is mandatory.

Key Duties and Responsibilities

• Precisely abstract and code relevant data from medical records within the CNExT cancer registry software, ensuring compliance with CCR reporting standards, Commission on Cancer requirements, and internal policies, maintaining an accuracy above 97%.
• Apply and verify radiation oncology treatment data by reviewing treatment summaries, consults, and the MOSAIQ Radiation Oncology database.
• Identify cancer cases from sources including pathology, radiology, and billing systems using CNExT and APEX (Epic) software.
• Evaluate cases to determine the necessity of sending correspondence for additional external staging, treatment, or diagnostic information.
• Conduct visual editing quality checks on up to 50 completed cases daily, providing expert review.
• Lead quality control initiatives such as re-abstracting audits, staging audits, and casefinding audits while assisting management with training new registrars pursuing CTR certification.

Qualifications and Requirements

• Minimum of five years in a hospital environment with at least three years dedicated to abstracting complex oncology cases, preferably in academic or NCI-designated comprehensive cancer centers.
• Comprehensive understanding of California Cancer Registry reporting criteria, cancer coding, and accreditation standards set by the American College of Surgeons' Commission on Cancer.
• In-depth knowledge of human anatomy, medical and oncology terminology, diagnostic methods, and treatment options.
• Proficiency in morphological and topographic coding using ICD-9 and ICD-O, as well as mastery of SEER and American Joint Committee on Cancer staging protocols (TNM).
• Strong computer literacy, including experience with CNExT software, Cancer Alert System (CAS), MS Word, Excel, and Epic electronic medical records.
• Ability to fully abstract cases within 1.5 to 2 hours for analytic cases and meet a monthly target of 80-100 cases when employed full-time.
• Capable of generating reports and conducting data analysis to assist clinicians and researchers.
• Excellent communication and written skills.
• Certain technical requirements include remote access using Citrix Receiver, installation capabilities for Big Fix security application, Pulse Secure and DUO two-factor authentication on Windows 10 system supporting DDPE encryption.
• Possession of current Certified Tumor Registrar (CTR) certification with ongoing maintenance of required continuing education units monitored by the National Cancer Registrars Association.

Additional Information

About UCSF:
The University of California, San Francisco (UCSF) stands as a premier institution devoted solely to health sciences, renowned worldwide for contributions in biomedical research, education, and patient care. With a strong commitment to diversity, equity, and inclusion, UCSF fosters an environment respectful of professionalism, diversity, and excellence.

Equal Opportunity Employer:
UCSF ensures all qualified candidates receive consideration without regard to race, gender identity, sexual orientation, religion, disability, veteran status, or other legally protected categories.

Salary:
Final compensation depends on experience and internal equity, subject to University approvals and collective bargaining agreements where applicable.