Job Description

How you will do it

The Quality Specialist – HEDIS (RN/LPN with clinical experience) will report to the Clinical Support Supervisor – HEDIS and be part of the Quality Team. Their main duties include chart retrieval and conducting thorough medical record reviews using proprietary tools and software. The role requires extensive knowledge of HEDIS measures to accurately and promptly abstract medical records for gap closure and other data collection, all while adhering to HIPAA Privacy and Security standards. Responsibilities also include retrieval follow-up and escalating issues as needed. Expertise in HEDIS and Quality Measures is used to meet productivity and quality targets, enhance measure compliance, and improve rate submissions according to NCQA guidelines and technical specifications.
50%
• Retrieve medical records via EMR or fax request, ensuring compliance with all HIPAA and member confidentiality requirements.
• Call provider offices to request or validate facility and provider addresses, and/or collect medical records for the HEDIS project.
• Upload records upon receipt.
• Document all outreach efforts.
• Maintain productivity level as specified by the QI Department.

50%
• Conduct Medical Record Abstraction and Research during the Medical Record Review Project.
• Use various software applications to support HEDIS operations by entering data and/or changing chase status for the identified chase(s).
• Utilize extensive knowledge of HEDIS measures to facilitate medical record abstraction for gap closure and additional data gathering.
• Create and research Pends. Maintain productivity level as specified by the QI Department
• Ensure compliance with all HIPAA and member confidentiality requirements.
• Perform all other assigned duties.

 

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.
Education Level: Bachelor's degree in Nursing, Associates Degree in Nursing, Diploma in Nursing
Experience: 5 years of recent HEDIS abstractions / overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, Inovalon, Reveleer).
What we look for
At least two consecutive HEDIS seasons with the same company. 2 years clinical experience and good understanding of medical terminology.
Knowledge, Skills and Abilities (KSAs) Proficiency
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 and related medical policies - Proficient
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