HEDIS Utilization Review Nurse

Central Florida Health Care•Winter Haven, FL

55d

About The Position

The HEDIS Utilization Review Specialist is responsible for performing comprehensive reviews of medical records to collect data required for HEDIS reporting. This role supports quality improvement initiatives by identifying gaps in care, validating clinical documentation, and ensuring compliance with NCQA (National Committee for Quality Assurance) standards.

Requirements

Strong knowledge of HEDIS measures and NCQA guidelines.
Proficient in EHR systems and chart review processes.
Detail-oriented with strong analytical and organizational skills.
Excellent communication and collaboration abilities.
Education: RN, LPN, LVN.
Experience: 2+ years of clinical experience in a healthcare setting.
License: Florida unrestricted license
BLS certification
Computer literacy
Knowledge of current professional nursing theory, practice, and techniques
Knowledge of current nursing practices in an outpatient primary care setting
Knowledge of assessment of patient needs and services
Knowledge of current professional nursing and pharmaceutical products, Universal Precautions, and emergency situations
Knowledge of basic pathophysiology of diseases commonly managed in Family Medicine
Knowledge of the application of nursing techniques (example: Triage, blood pressure monitoring, glucose monitoring, etc.)
Knowledge of patient teaching and education (example: self-blood pressure monitoring, nutrition instruction, diabetes self-care instruction)
Knowledge of general patient care and treatment procedures, equipment, rules, regulations, and ethics
Knowledge of Utilization Review Accreditation Commission (URAC) Policies and Procedures
Knowledge of processing and obtaining prior authorizations
Knowledge of making observations of general physical condition and needs of patients and when to confer with a physician about the emotional or physical condition of a patient
Knowledge of the principles of aseptic and sterile techniques and infection control techniques
Knowledge of the techniques of administration of common medications, including immunizations, inoculations, and allergy injections using sterile technique, and knowledge of the side effects of these medications
Knowledge of state and federal drug control laws, rules, and regulations
Knowledge of emergency techniques and procedures
Knowledge of common medical supplies and equipment
Excellent interpersonal, communication and leadership skills
Ability to demonstrate priority-setting and ability to work in a complex environment
Ability to function with a high degree of independence and collaboration with other health care providers
Commitment to service, quality, and departmental core values
Be familiar with CFHC's program philosophies, goals and objectives. Be cognizant of and comply with all CFHC's policies and procedures, as well as state and federal regulations.
Be competent in performing the duties of a nurse.
Understand the requirements of CFHC's Exposure Control Plan. Personally, utilize universal precautions when practicing in a clinical setting.
Participate in staff outreach and off-site health care programs as requested by the DMC, ACMO, CMO, or CEO. Represent CFHC in the community.
Report as needed to DMC and any pertinent information or situations that impact on patient care or CFHC liability.
Attend and participate in mandatory CFHC meetings (Center Specific meetings, Corporate meetings, and other meetings as designated by the DMC, ACMO, CMO, or CEO).
Demonstrate ability to work cooperatively with other members of the clinical team. Be supportive of coworkers.
Maintain a neat and professional appearance at all times.
Carry out any other activities deemed appropriate by the DMC, CMO, or CEO.

Nice To Haves

Prior experience with HEDIS abstraction or utilization review strongly preferred.

Responsibilities

Review medical records and clinical data for HEDIS-specific measures.
Abstract and input accurate clinical data from electronic health records (EHRs) into reporting tools.
Identify and report documentation deficiencies or care gaps.
Collaborate with providers, coders, and clinical teams to ensure proper documentation and follow-up.
Assist in the coordination and execution of the annual HEDIS data collection cycle.
Maintain knowledge of current HEDIS specifications and regulatory updates.
Support audits and internal quality improvement initiatives related to clinical outcomes.
Ensure HIPAA compliance and confidentiality of patient information.
Assess, identify problems, plan goals, monitor and evaluate patient plans, and develop strategies that meet the patients immediate and long-term goals.
Work closely with PCP to manage patient "care items" which could include; medication refills per protocol, lab triage, document management, management of durable medical equipment (i.e. Glucometer, test strips, lancets), prior authorizations of needed medications or other services.
Use patient data to track and schedule follow up appointments.
Provide proactive utilization management for patients with high risk needs.
Assist patients in obtaining appropriate medications and medical supplies and equipment, including coordination of pharmaceutical patient assistance programs.
Participate in quality improvement, quality assurance and innovation activities to ensure optimal level of care delivery.
This position will ensure all HEDIS measures have been met for those assigned patients and all care gaps have been identified.
Assist in the coordination of warm hand-offs or "transfer of trust" between care team, pharmacy or other support services during the office visit.
Carry out other duties as assigned by the DMC.

Benefits

Competitive Salary
Federal Student Loan Forgiveness: PSLF - 10-year commitment, 120 loan payments and at the end of the commitment, the remaining loan is forgiven
Excellent medical, dental, vision, and pharmacy benefits
Employer Paid Long-Term Disability Insurance
Employer Paid Life Insurance equivalent to 1x your annual salary
Voluntary Short-Term Disability, additional Life and Dependent Life Insurance are available
Malpractice Insurance
Paid Time Off (PTO) - 4.4 weeks per year pro-rated
Holidays (9.5 paid holidays per year)
Paid Birthday Holiday
CME Reimbursement
401k Retirement Plan after 1 year of service (w/matching contributions)
Staff productivity is recognized and rewarded