Health Services - Nurse, Clinical Medical Review

Talteam Inc. • Columbia, MD

8d • Onsite

About The Position

The Clinical Medical Review Specialist is a professional with clinical experience who will report to the Clinical Support Supervisor – HEDIS and be part of the Quality Team. The main duties include chart retrieval, using proprietary tools and software to conduct thorough medical record reviews in line with NCQA specifications, retrieval follow-up, and escalating issues as needed. Main duties will be assigned according to experience, knowledge, skills, and abilities. This role requires extensive knowledge of HEDIS measures to accurately and expediently abstract medical records, all while adhering to HIPAA Privacy and Security standards. Additional tasks involve helping with EMR Medical Record Retrieval for HEDIS, contacting provider offices to request or validate facility and provider contact information and record retrieval preference, and/or requesting medical records for the HEDIS project and supporting other needs within the Quality Department.

Requirements

• Bachelor's degree in Nursing, Associate's degree in Nursing, or Diploma in Nursing OR 10 years of relevant HEDIS abstraction and/or overread experience in a payer, health insurance, or HEDIS vendor environment.
• Registered Health Information Associate/Registered Health Information Technician, Nursing, or a related clinical or healthcare field.
• Candidates qualifying in lieu of a degree must have 10 years of recent, directly relevant HEDIS medical record abstraction and/or overread experience within a payer, health insurance, or HEDIS vendor setting, including demonstrated knowledge of NCQA HEDIS specifications and abstraction platform workflows.
• 3 years of clinical experience
• 5 years of HEDIS experience
• Qualified RN or LPN with experience supporting HEDIS reporting and abstraction processes in a payer, health insurance, or HEDIS vendor environment.
• Understanding of NCQA healthcare quality metrics
• Proven ability to accurately abstract, interpret, and document medical record data for HEDIS gap closure.
• Detail-oriented
• Able to work independently
• Maintain a high level of accuracy
• Proficiency with Microsoft Office, including Excel, Word, PowerPoint, Microsoft Teams, and Outlook.
• Experience retrieving medical records from EMR platforms such as Epic, eClinicalWorks, Athena, Cerner, Allscripts, and Tebra is essential.
• Current knowledge of clinical practices related to HEDIS and medical record review.
• Strong organizational skills, including the ability to prioritize responsibilities, maintain attention to detail, and shift tasks as needed.
• Experience using Microsoft Office applications, including Excel, Word, and PowerPoint, as well as web-based technology.
• Excellent verbal and written communication skills.
• Strong interpersonal skills, with the ability to work independently and as part of a team.

Nice To Haves

• HEDIS overread experience with a health plan or HEDIS vendor is preferred.
• At least two recent consecutive HEDIS seasons with the same company.

Responsibilities

• Chart retrieval
• Using proprietary tools and software to conduct thorough medical record reviews in line with NCQA specifications
• Retrieval follow-up
• Escalating issues as needed
• Helping with EMR Medical Record Retrieval for HEDIS
• Contacting provider offices to request or validate facility and provider contact information and record retrieval preference
• Requesting medical records for the HEDIS project
• Supporting other needs within the Quality Department

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level