Purpose
The Clinical Medical Review Nurse (an RN with clinical experience) will report to the Clinical Support Supervisor - HEDIS and be part of the Quality Team. The main duties include conducting thorough HEDIS overreads in line with NCQA guidelines. Additional tasks involve helping with Medical Record Retrieval for HEDIS and Risk Adjustment, participating in internal audits for Supplemental Data, and supporting other needs within the Quality Department.
Essential Functions
50% Accurately and efficiently over-read medical record abstractions performed by the HEDIS abstraction staff on a daily basis according to HEDIS specifications and company training guidelines.
Complete the over-read process in the Software Application, including comments if errors are found. Correct errors identified through over-read process, including a re-review of charts that may contain similar errors.
Identify and report abstraction errors and provide measure re-education with the abstractor.
Utilizes various software applications to support HEDIS operations by entering data and / or changing chase status for the identified chase(s).
Maintains productivity level as determined by the QI Department.
Maintain compliance with all HIPPA and member confidentiality requirements.
All other duties as assigned.
25% Medical Record Retrieval, Abstraction and Research during the Medical Record Review Project
25% Medical Record Retrieval for Risk Adjustment, internal Supplemental Data Audit (PSV) and other Quality and HEDIS related tasks in the off-season
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Experience: 3 years clinical experience, and 5 years HEDIS and Overread experience.
In Lieu of Education
10 years of recent HEDIS abstractions / overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, Inovalon, Reveleer)
Preferred Qualifications
Bachelor's degree in Nursing, Associates Degree in Nursing, Diploma in Nursing
At least two consecutive HEDIS seasons with the same company.
Knowledge, Skills And Abilities (KSAs)
Ability to effectively communicate and provide positive customer service to every internal and external customer - Proficient
Strong interpersonal skills. Ability to work independently, as well as a member of a team - Advanced
Current knowledge of clinical practices related to HEDIS and Medical Record Review - Advanced
Strong organizational skills, ability to prioritize responsibilities with attention to detail. - Proficient
Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology - Proficient
Must possess excellent verbal and written communication skills - Advanced
We are seeking a qualified RN/LPN with experience in HEDIS reporting and overread processes. The ideal candidate will have a robust understanding of healthcare quality metrics and a proven track record of accurate data abstraction and interpretation. Applicants must be detail-oriented and able to work independently while maintaining a high level of accuracy. Prior experience in HEDIS and overread review is essential for this role.
Licenses/Certifications
RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD Upon Hire Req
