Remote HEDIS Nurse Reviewer – New England Region

Martin's Point Health Care•Portland, ME

1d•Remote

About The Position

Martin's Point Health Care is seeking a Nurse HEDIS Reviewer and Auditor, a registered nurse responsible for performing clinical reviews of healthcare data, focusing on HEDIS measures and quality improvement. This role 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. Martin's Point Health Care is an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Martin's Point has been certified as a "Great Place to Work" since 2015.

Requirements

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.
Active and unrestricted Nursing license.
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.

Responsibilities

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.