HEDIS Quality Improvement Nurse

Community Health Plan of Washington•Seattle, WA

16h•$80,940 - $125,460

About The Position

The HEDIS Quality Improvement Nurse performs medical record review audits and analysis for regulatory NCQA and CMS audits. The role supports the Manager with provider audit reports and education, identifies process-improvement opportunities, and performs overreads and peer reviews of other team members’ work. The position supports updates to HEDIS medical record review and coding guidelines, completes annual regulatory quality-assurance and validation workflows, reviews documentation and coding for compliance, and communicates audit findings and recommendations to internal teams, providers, and vendors. It also serves as a subject-matter resource for medical record review and coding and supports regulatory data-validation audits. This is an FLSA-exempt position that is not eligible for overtime. The position has a 10% annual incentive target based on company, department, and individual performance goals. Candidates must pass a criminal background check, have no applicable sanctions or exclusions from federal or state health care programs, and meet the vaccination requirement, with a process for medical or religious exemptions. Reasonable accommodations are available for qualified candidates with disabilities.

Requirements

Licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN).
At least five years of combined experience performing NCQA, HEDIS, and CMS Medicare Star measure medical record and coding review, and conducting documentation and coding.
Experience with Microsoft Office Suite, including Word, Excel, Outlook, and Internet Explorer, and Adobe Acrobat; comfort with pivot tables at a minimum.
Knowledge of acceptable medical record and coding standards and criteria within NCQA HEDIS Technical Specifications and Medicare Part C & D Star Technical Notes.
Strong written and verbal communication skills.
Strong organizational, time-management, and work-prioritization skills.
Ability to design and update provider feedback reports.
Strong analytical skills and ability to interpret and evaluate data and formulate action plans.
Successfully pass a criminal background check.
Must not have been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law-enforcement, regulatory, or licensing agency.
Meet the vaccination requirement; CHPW offers a process for medical or religious exemptions.
Ability to perform the essential functions of the job, with reasonable accommodation if needed.

Nice To Haves

Bachelor’s degree in nursing or an equivalent combination of education and highly relevant experience.
Experience with SharePoint, Confluence, and Smartsheet.
Knowledge and experience with natural language processing (NLP) and computer-assisted medical record review and coding applications.
Applied understanding of reimbursement-based CMS Medicare Stars principles and State Value Base program experience.

Responsibilities

Support updates and maintenance of CHPW HEDIS medical record review and coding guidelines to reflect changes to NCQA HEDIS Technical Specifications and Medicare Part C & D Star Technical Notes; interpret changes and support policy modifications in coordination with the HEDIS Performance Measurement Manager and HEDIS Program Manager.
Stay current on regulatory, medical record documentation, and coding issues and best practices, including NCQA Guidelines for Medical Record Documentation, Coding and Reporting.
Present findings verbally and in writing to internal audiences, department leadership, provider and clinical teams, peers, and vendor support teams.
Update and distribute provider feedback reports to the HEDIS Performance Manager and help create materials about significant audit findings, trends, and recommendations for training, oversight, monitoring, process changes, and documentation and coding education.
Serve as a medical record review and coding subject-matter expert; support overreads and validation of colleagues’ documentation performance.
Complete the annual regulatory HEDIS medical record review and coding quality-assurance process, including primary-source validation and retrospective medical record and coding audits.
Identify and implement quality-assurance practices and process improvements.
Monitor and comply with internal medical record and coding guidelines, department policies, and NCQA/CMS quality program guidelines, rules, and regulations.
Continuously develop knowledge of Medicare, Medicaid, and Exchange programs and applicable regulatory documentation and coding practices.
Support chart audit processes and verify that provider and vendor documentation meets NCQA HEDIS and CMS Medicare Stars requirements.
Liaise between internal departments on regulatory data-validation audits, including Primary Source Validation, Prospective Medical Record Review, and Retrospective (Hybrid) Medical Record Review.
Perform root-cause analysis to identify issues that may contribute to medical record documentation and coding problems.
Perform internal and external coding quality reviews to validate medical record documentation and coding.
Perform other duties as assigned; listed essential functions may be revised at the employer’s discretion.

Benefits

Medical, prescription, dental, and vision coverage.
Telehealth app.
Flexible Spending Accounts and Health Savings Accounts.
Basic life and AD&D insurance, short- and long-term disability insurance.
Voluntary life, critical care, and long-term care insurance.
401(k) retirement plan with employer match.
Employee Assistance Program and Mental Fitness app.
Financial coaching and identity theft protection.
PTO accrual starting at 17 days per year.
40 hours of community-service volunteer time.
10 standard holidays and 2 floating holidays.
Compassion time off and jury duty pay.
10% annual incentive target based on company, department, and individual performance goals.