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Position SummaryThe Nurse HEDIS Reviewer and Auditor is a registered nurse responsible for performing clinical reviews of healthcare data, focusing on HEDIS measures and quality improvement. This position requires strong clinical knowledge and expertise to accurately extract and audit patient data, ensuring it meets HEDIS standards. The Nurse HEDIS Reviewer and Auditor collaborates with cross-functional teams, participates in quality improvement initiatives, and provides clinical insights to enhance healthcare outcomes and compliance with quality benchmarks.
Job Description
Key Outcomes:
- Performs clinical chart reviews and audits to ensure accuracy and compliance with HEDIS measures.
- Develops reports to identify HEDIS care gaps and trends and works closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements.
- Prioritizes reports according to business needs, regulatory requirements, urgency, and other key business factors.
- Assists in the coordination of outreach efforts to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications.
- Collaborates with health plan departments to identify HEDIS data sources and develop systems to capture this data in accordance with HEDIS technical specifications, such as supplemental databases.
- Collaborates with data analysts and quality teams to support performance improvement.
- Documents findings and recommend strategies to improve HEDIS measure performance.
- Applies clinical expertise to identify and validate data discrepancies.
- Educates non-clinical staff on HEDIS requirements and clinical relevance of data.
- Corresponds with members and clinical providers to effectively coordinate care, obtain medical records and ensure patients receive preventive and chronic disease management services.
- Develops on-going training and education for both internal and external stakeholders.
- Completes annual training provided and meet and maintain competency and acceptable performance goals.
- Other duties and responsibilities, as assigned.
Education/Experience:
- Bachelor’s degree in nursing required
- 5+ years of experience in the health care industry, in HEDIS and/or quality improvement.
- Experience in managed care health services environment
- NCQA and HEDIS Experience.
Required License(s) and/or Certification(s):
- Active and unrestricted Nursing license.
Skills/Knowledge/Competencies (Behaviors):
- Demonstrated knowledge of data collection, medical record review, and data extraction.
- Excellent communication, organization and writing skills.
- Ability to effectively prioritize work, multi-task, and achieve goals on time; work independently and to self-motivate.
- Excellent critical thinking skills.
- Keen attention to detail.
- Ability to work effectively and collaboratively with internal and external stakeholders.
- Knowledge of, and skills in, data collection, analysis, and presentation.
- Excellent oral and written communication skills.
- Must demonstrate integrity, sound judgement and strong interpersonal skills.
- Strong knowledge of medical terminology.
- Strong clinical knowledge and understanding of evidenced-based practice principles and the ability to define appropriate sources for standards of care.
- Must be able to address quality issues with tact and diplomacy.
- Proficient use of MS Office with a focus on Excel and report writing software.
- Proficiency in use of electronic medical records and computer applications.
- Ability to use data to make decisions.
There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]
Do you have a question about careers at Martin’s Point Health Care? Contact us at:[email protected]
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