HEDIS Nurse Reviewer – New England Region

Job Description:

• 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.
• Assists in the coordination of reputed company 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 reputed company 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 recommends 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.

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 reputed company services environment
• NCQA and HEDIS Experience
• Active and unrestricted Nursing license

Benefits:

• Health care coverage
• Professional development opportunities
• Annual training provided

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