HEDIS Clinical Review Specialist

We are seeking a qualified RN / LPN with experience in HEDIS reporting and overread processes. The ideal candidate will have a robust understanding of healthcare quality metrics and a proven track record of accurate data abstraction and interpretation. Applicants must be detail-oriented and able to work independently while maintaining a high level of accuracy. Prior experience in HEDIS and overread review is essential for this role.

Licenses / Certifications

RN - Registered Nurse - State Licensure And / or Compact State Licensure RN-VA, DC and or MD Upon Hire Req

The Clinical Medical Review Nurse (an RN or LPN with clinical experience) will report to the Clinical Support Supervisor – HEDIS and be part of the Quality Team. The main duties include conducting thorough HEDIS overreads in line with NCQA guidelines. Additional tasks involve helping with Medical Record Retrieval for HEDIS and Risk Adjustment, participating in internal audits for Supplemental Data, and supporting other needs within the Quality Department.

MUST HAVE HEDIS EXPERIENCE.

50% Accurately and efficiently over-read medical record abstractions performed by the HEDIS abstraction staff on a daily basis according to HEDIS specifications and company training guidelines.

Complete the over-read process in the Software Application, including comments if errors are found. Correct errors identified through over-read process, including a re-review of charts that may contain similar errors.

Identify and report abstraction errors and provide measure re-education with the abstractor.

Utilizes various software applications to support HEDIS operations by entering data and / or changing chase status for the identified chase(s).

Maintains productivity level as determined by the QI Department.

Maintain compliance with all HIPPA and member confidentiality requirements.

All other duties as assigned.

25% Medical Record Retrieval, Abstraction and Research during the Medical Record Review Project

25% Medical Record Retrieval for Risk Adjustment, internal Supplemental Data Audit (PSV) and other Quality and HEDIS related tasks in the off-season

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions.

Experience : 3 years clinical experience, and 5 years HEDIS and Overread experience.

Vega Consulting Solutions, Inc. is searching for a Clinical Medical Review Nurse for 6 month Contract opportunity with our direct client. This is a hybrid position and the resource must reside within the service area. Candidates must be located in the Baltimore Maryland area. Sponsorship is not available.

The Clinical Medical Review Nurse handles day to day review of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and / or adjudication. The incumbent will handle pre and post claim medical review for Commercial, and Medicare Advantage Plans. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies. This role will also understand the merits of legal or accreditation actions.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions.

Experience : 3 years acute clinical experience, previous case management, discharge planning or utilization review experience

Bachelor's degree in Nursing

Ability to effectively communicate and provide positive customer service to every internal and external customer, Proficient

Strong interpersonal skills. Ability to work independently, as well as a member of a team , Advanced

Current knowledge of clinical practices and related medical policies., Proficient

Strong organizational skills, ability to prioritize responsibilities with attention to detail., Proficient

Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology., Proficient

Must possess excellent verbal and written communication skills. , Advanced

The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Licenses / Certifications

RN - Registered Nurse - State Licensure And / or Compact State Licensure RN-VA, DC and or MD Upon Hire Req

LPN_Licensed Practical Nurse

If your back ground matches the above skill set and you are open to Contract opportunities, please select Apply Now and a Vega Staffing Specialist will reach out to you.