Temporary Nurse HEDIS Reviewer
About The Position
The HEDIS Nurse Reviewer is a registered nurse responsible for clinical reviews of healthcare data, with a focus on HEDIS measures and quality improvement. The role uses clinical knowledge to extract and audit patient data, confirm that records meet HEDIS standards, and provide clinical insights that support improved outcomes and compliance with quality benchmarks. The reviewer conducts clinical record reviews, data validations, and overreads; identifies care gaps and trends; and collaborates with providers and care teams to obtain and document clinical services. The position also supports health plan quality programs and regulatory reporting, analyzes opportunities for process improvement, and educates non-clinical staff on HEDIS requirements. The reviewer maintains required training and meets productivity standards set by the HEDIS supervisor.
Requirements
- Bachelor's degree in nursing.
- Active and unrestricted nursing license.
- At least 5 years of experience in the health care industry, in HEDIS and/or quality improvement.
- Experience in a managed care health services environment.
- NCQA and HEDIS experience.
- Ability to navigate multiple EMR and health plan applications.
- Intermediate proficiency in Microsoft Word, Excel, and Adobe.
- Strong organizational skills and attention to detail.
Nice To Haves
- Certified Coder certification.
Responsibilities
- Perform clinical record reviews, data validations, and overreads to ensure accuracy and compliance with HEDIS measures.
- Develop reports to identify HEDIS care gaps and trends, and work with providers to ensure services are provided and documented according to HEDIS requirements.
- Analyze patterns and root causes and identify opportunities for process and performance improvement.
- Support Health Plan Quality programs and reporting for regulatory requirements, including CMS, DHA, and NCQA.
- Prioritize reports based on business needs, regulatory requirements, urgency, and other key business factors.
- Assist with outreach to request, collect, and secure clinical documentation from providers or provider groups as specified by HEDIS measures.
- Identify, collect, document, and store HEDIS data according to standard operating procedures and HEDIS technical specifications.
- Apply clinical judgment to validate diagnoses, procedures, exclusions, and documentation elements.
- Educate non-clinical staff on HEDIS requirements and the clinical relevance of data.
- Collaborate with physicians, office staff, and care teams to obtain medical records, support quality initiatives, provide education on measure requirements and documentation standards, identify coding opportunities, and facilitate timely gap closure.
- Maintain NCQA and other required training and meet productivity standards as directed by the HEDIS supervisor.
- Perform other duties and responsibilities as assigned.
- Demonstrate the organization's mission, vision, and core values consistently.
