HEDIS Clinical Medical Review Specialist

Elite Technical • Baltimore, MD

87d

About The Position

We are seeking a HEDIS Clinical Medical Review Specialist (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

• RN or LPN certified is required. License in DC, MD or VA (Licensure Compact-(NLC) acceptable).
• Bachelor's or Associates degree in Nursing is highly preferred with 5 years of HEDIS experience and 3 years of clinical experience (10 years without Degree is required).
• Background in medical case management, discharge planning or utilization review experience. Current knowledge of clinical practices and related medical policies.
• Must have recent HEDIS abstractions/overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, CareSeed, Inovalon, Reveleer) experience.
• Expertise within any EMR is required (Big Plus would be Epic, eClinical or Cerner).
• Ability to effectively communicate and provide positive customer service to every internal and external customer.
• Must have solid MS Office (entire suite) knowledge.

Responsibilities

• Call provider offices to request or validate facility/provider contact information specifically for HEDIS medical record retrieval. Document all outreach efforts.
• Retrieve medical records via EMR that meet HEDIS requirements and ensure compliance with HIPAA. Upload charts to abstraction platform upon receipt.
• Use extensive knowledge of HEDIS measures to facilitate accurate and efficient data abstraction from charts within the abstraction platform on a daily basis according to HEDIS specifications and company training guidelines.
• Use various software applications to support HEDIS operations by creating and researching clinical and retrieval pends.
• Other duties as assigned.

What This Job Offers

• Career Level: Mid Level
• Education Level: Bachelor's degree