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HEDIS Nurse Reviewer
The primary purpose of the job is to:
Provide nursing support to the Quality Management Department during HEDIS Medical Record Review (MRR) season with a current unrestricted SC Licensed Practice Nurse,. The HEDIS Nurse Reviewer will work with the HEDIS team to collect member records by working with provider offices and/or hospital facilities via telephone or on-site visits. The HEDIS Nurse must possess basic clinical and healthcare knowledge, basic knowledge of NCQA HEDIS abstracting guidelines, with the ability to access medical records (electronic and paper). The Nurse must be able to accurately identify required data and information, extract and organize this data and enter into a database.
The HEDIS Nurse Reviewer will perform medical records abstraction in support of annual The Healthcare Effectiveness Data and Information Set (HEDIS), with duties including but not limited to:
Applies structured auditing criteria to medical records to determine compliance with standards
Maintains productivity level as determined by the Quality Management Director;
Accurately enters the results of chart audits into a database;
Monitors progress towards completion of the annual HEDIS chart abstraction process; Maintains a less than 1% error rate in record abstraction and data entry;
Utilizes various software applications (e.g., , Quality Spectrum Insight, Excel and Word) to support HEDIS operations;
As required: visits to provider sites to identify copy and collect selected medical records; and
Performs additional duties as assigned.
Experience with abstracting clinical information from medical records with duties including but not limited to:
Clinical experience in women’s health care, diabetes, pediatrics or obstetrics preferred;
The ability to consistently apply clinical audit criteria with at least a 99% inter-rater reliability;
The ability to consistently enter the results of clinical audits into a database with at least a 99% inter-rater reliability;
The ability to appropriately evaluate medical records and other health care data; Organized, accurate, detail-oriented;
Able to think and work effectively under pressure;
Experience pertaining to health care quality improvement or clinical research preferred;
Familiarity with ICD-10 and CPT coding preferred.
The ability to function effectively within multidisciplinary teams;
Experience with the use of Windows-based PC applications with emphasis on word processing, database, and spreadsheet software (e.g., MS Word and Excel) preferred;
Knowledge of NCQA HEDIS abstracting guidelines preferred; Ability to plan and organize data collection activities;
Ability to communicate effectively both orally and in writing; Knowledge of the concepts of managed health care;
Ability to establish and maintain effective and cooperative working relationship with staff and others contacted in the course of the work;
Ability to maintain confidentiality of sensitive medical information: Knowledge of The HIPAA Privacy and Security Rules
Ability to accurately complete tasks within established times; and
Ability to effectively prioritize multiple tasks and deadline
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