Purpose:
The Clinical Medical Review Nurse will be a key member of the Quality Team, conducting thorough HEDIS overreads in accordance with NCQA guidelines. This role will also involve supporting Medical Record Retrieval for HEDIS and Risk Adjustment, participating in internal audits for Supplemental Data, and addressing other needs within the Quality Department. A strong emphasis will be placed on maintaining detailed call notes and documentation throughout the review process to ensure effective communication and collaboration.
Key Responsibilities:
- HEDIS Overreads:
- Conduct accurate and efficient overreads of medical record abstractions performed by HEDIS abstraction staff, adhering to HEDIS specifications and training guidelines.
- Complete the over-read process in the software application, including documenting comments for any errors identified.
- Correct errors found during the over-read process, which may require a re-review of charts with similar errors.
- Identify and report abstraction errors, providing measure re-education to the abstractor.
- Medical Record Retrieval and Research:
- Participate in Medical Record Retrieval for HEDIS, Risk Adjustment, and internal Supplemental Data Audits.
- Utilize various software applications to support HEDIS operations by entering data and updating chase statuses as necessary.
- Compliance and Quality Assurance:
- Maintain compliance with HIPAA and member confidentiality requirements throughout all tasks.
- Meet productivity levels as determined by the Quality Improvement (QI) Department.
Qualifications:
Experience:
- Minimum of 3 years of clinical experience.
- 5 years of experience with HEDIS and overreading processes.
In Lieu of Education:
- 10 years of recent HEDIS abstractions or overreads experience within the payer or health insurance sectors, or with a HEDIS vendor (e.g., Cotiviti, Inovalon, Reveleer).
Preferred Qualifications:
- Bachelor’s degree in Nursing, Associate’s Degree in Nursing, or a Diploma in Nursing.
- At least two consecutive HEDIS seasons with the same organization.
Knowledge, Skills, and Abilities (KSAs):
- Proficient in effectively communicating and providing positive customer service to both internal and external stakeholders.
- Advanced interpersonal skills, with the ability to work independently and collaboratively as part of a team.
- Comprehensive knowledge of clinical practices related to HEDIS and medical record review.
- Strong organizational skills with the ability to prioritize responsibilities while paying attention to detail.
- Proficient in using Microsoft Office (Excel, Word, PowerPoint) and web-based technology.
- Excellent verbal and written communication skills.
Licenses/Certifications:
- RN - Registered Nurse - State Licensure and/or Compact State Licensure (VA, DC, MD) upon hire is required.
Additional Skills:
- Proficient in NCQA standards, HEDIS measures, medical records, clinical experience, and medical terminology.
