HEDIS Nurse Reviewer for Quality Improvement

Martin's Point Health Care; Portland (ME); Sur place; USD 87 000 - 107 000; Plein temps

Résumé du poste

Martin's Point Health Care in Maine is seeking an experienced HEDIS Nurse Reviewer, a registered nurse responsible for clinical reviews of healthcare data, focusing on HEDIS measures and quality improvement. The role requires strong clinical knowledge to extract and audit patient data for accuracy and compliance with HEDIS standards.

You will collaborate with physicians and care teams to close care gaps, generate reports, and support regulatory reporting for CMS/NCQA.

Qualifications

• Bachelor's degree in nursing required.
• Active and unrestricted Nursing license.
• Certified Coder certification preferred.
• 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.
• Ability to navigate multiple EMR and health plan applications.
• Proficient with Word, Excel and Adobe.

Responsabilités

• Performs clinical record reviews, data validations, and overreads to ensure accuracy and compliance with HEDIS measures.
• Develops reports to identify HEDIS care gaps and trends and work closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements.
• Conducts analysis to identify patterns, root causes, and opportunities for process and performance improvement.
• Supports Health Plan Quality programs and reporting for regulatory requirements (CMS, DHA, NCQA, etc.).
• Prioritizes reports according to business needs, regulatory requirements, urgency, and other key business factors.
• Assists in the coordination of outreach efforts as needed to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications.
• Identifies, collects, documents, and stores HEDIS data in accordance with standard operating procedures and HEDIS technical specifications.
• Applies clinical judgement to validate diagnosis, procedures, exclusions, and documentation elements.
• Educates non-clinical staff on HEDIS requirements and clinical relevance of data.
• Collaborates with physicians, office staff, and care teams to obtain medical records, support HEDIS quality initiatives, provide education on HEDIS measure requirements, documentation standards, and coding opportunities and facilitate timely gap closure activities.
• Maintains NCQA and other training requirements and meet productivity standards as directed by the HEDIS supervisor.
• Other duties and responsibilities, as assigned.

Connaissances

EMR navigation

Attention to detail

Microsoft Word

Microsoft Excel

Adobe

Formation

Bachelor’s degree in nursing

Outils

EMR software

Description du poste

Martin's Point Health Care in Maine is seeking an experienced HEDIS Nurse Reviewer, a registered nurse responsible for clinical reviews of healthcare data, focusing on HEDIS measures and quality improvement. The role requires strong clinical knowledge to extract and audit patient data for accuracy and compliance with HEDIS standards.

You will collaborate with physicians and care teams to close care gaps, generate reports, and support regulatory reporting for CMS/NCQA.