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Position Summary
 

The HEDIS Nurse Reviewer 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 HEDIS Nurse Reviewer participates in quality improvement initiatives and provides clinical insights to enhance healthcare outcomes and compliance with quality benchmarks.

Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

• Performs clinical record reviews, data validations, and overreads to ensure accuracy and compliance with HEDIS measures.
• Develops reports to identify HEDIS care gaps and trends and work closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements.
• Conducts analysis to identify patterns, root causes, and opportunities for process and performance improvement.
• Supports Health Plan Quality programs and reporting for regulatory requirements (CMS, DHA, NCQA, etc.).
• Prioritizes reports according to business needs, regulatory requirements, urgency, and other key business factors.
• Assists in the coordination of outreach efforts as needed to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications.
• Identifies, collects, documents, and stores HEDIS data in accordance with standard operating procedures and HEDIS technical specifications.
• Applies clinical judgement to validate diagnosis, procedures, exclusions, and documentation elements.
• Educates non-clinical staff on HEDIS requirements and clinical relevance of data.
• Collaborates with physicians, office staff, and care teams to obtain medical records, support HEDIS quality initiatives, provide education on HEDIS measure requirements, documentation standards, and coding opportunities and facilitate timely gap closure activities.
• Maintains NCQA and other training requirements and meet productivity standards as directed by the HEDIS supervisor.
• Other duties and responsibilities, as assigned.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

POSITION QUALIFICATIONS

Education:

• Bachelor’s degree in nursing required.

Licensure/certification:

• Active and unrestricted Nursing license.
• Certified Coder certification preferred.

Experience:

• 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.

Skills:

• Ability to navigate multiple EMR and health plan applications.
• Intermediate level of Microsoft Word, Excel and Adobe.

Abilities:

• High organization and strong attention to details.

Pay Range: $86,926.10 - $107,379.30 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan.

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]