RN Quality & HEDIS Nurse Specialist

Jefferson Health; Philadelphia (Philadelphia County); On-site; USD 90,000 - 120,000; Full time

Job summary

Jefferson Health is seeking a Clinical STARS-HEDIS Specialist to support the Quality Management department and drive care gap closure. The role involves provider outreach, medical record reviews, and collaboration across Care Management, HEDIS, UM, enrollment, and member services to improve Stars, NCQA Accreditation, CAHPS, and PCMH outcomes.

Ideal candidates will have a Nursing degree, 3+ years in managed care or quality review, and strong communication, problem solving, and teamwork skills.

Qualifications

• Bachelor’s degree in Nursing required.
• Minimum 3 years in managed care, clinical case management, or quality review.
• Proficient with Microsoft Office, SharePoint, and Teams.
• Knowledge of clinical case management and medical terminology.
• Ability to read and interpret standards for job functions.
• Excellent presentation, oral/written communication, interpersonal, problem solving, multitasking and time management.
• Exceptional customer service skills.
• Ability to work independently and in a team.
• RN license in PA, PA Driver's License.

Responsibilities

• Conduct provider outreach calls to complete clinical/quality assessments related to HEDIS and Stars, including pain and functional assessments.
• Perform quality medical record reviews to ensure care management effectiveness and report gaps to PCP.
• Assist Quality Management with chart reviews/overreads during HEDIS season.
• Identify quality issues and recommend potential solutions.
• Share best practices and support process improvement initiatives.
• Collaborate with HEDIS, Care Management, UM, enrollment, member services, and Grievances to resolve quality concerns.
• Document in Care Management systems, Access, Excel per requirements.
• Operate CIC and telephone systems per security and information exchange protocols.
• Other duties as assigned.

Skills

RN license

PA license

Driver's license

Microsoft Office

SharePoint

Teams

Clinical knowledge

Communication

Independent & team work

Education

Bachelor’s Degree in Nursing

Tools

Microsoft Office

SharePoint

Teams

Job description

Jefferson Health is seeking a Clinical STARS-HEDIS Specialist to support the Quality Management department and drive care gap closure. The role involves provider outreach, medical record reviews, and collaboration across Care Management, HEDIS, UM, enrollment, and member services to improve Stars, NCQA Accreditation, CAHPS, and PCMH outcomes.

Ideal candidates will have a Nursing degree, 3+ years in managed care or quality review, and strong communication, problem solving, and teamwork skills.