HEDIS / STARS Nurse (RN/LPN)

POSITION SUMMARY

This position is responsible for the coordination of HEDIS and STARs data gathering process. This evaluates the quality and completeness of clinical documentation processes by performing quality medical record reviews, assisting in the improvement of the clinical documentation process, identifying trends, maintaining accurate records of review activities, ensuring all data submitted to the health plan meets the HEDIS/Star technical specifications for medical records. contribute to a positive, patient-centered care experience. This role is essential to improving quality performance, supporting HEDIS and Stars initiatives, and enhancing overall member satisfaction.

Position is onsite Monday-Friday.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Provide excellent customer service by addressing patients and client needs promptly and courteously.
• Phone calls to patients for scheduling or education on HEDIS Measures.
• Perform on-site facility audits for compliance with HEDIS measures.
• Prepare and present HEDIS compliance reports to health facility managers.
• Train and advise healthcare professionals and administrative staff on HEDIS compliance.
• Assisting in the review of medical records to highlight Star/HEDIS opportunities for the medical staff.
• Review medical records for data collection, data entry, and quality monitoring including health plan form submission and chart collection activities that close gaps in care and meeting daily abstraction goals and maintain a high abstraction accuracy percentage.
• Partner with the leadership team, the practice administrative or clinical staff to identify trends observed and potential strategies to support the practice.
• Communicate scheduling challenges or trends that may negatively impact quality outcomes.
• Track and trend barriers/challenges that exist at their assigned groups so that better outcomes can be achieved including access to appointments, lack of follow up on referrals, or inconsistent billing practices.
• Activities may include data collection, data entry, quality monitoring, health plan form submission and chart collection activities.
• Assists with local IRR audits.
• Navigate multiple documentation systems and obtain medical record sections supportive of HEDIS/Star measures.
• Support chart chase process by requesting records from provider's offices as needed.
• Maintains education/knowledge base of HEDIS/STARs.
• Performs all other related duties as assigned.

QUALIFICATIONS AND EDUCATION

Required qualifications:

• Bilingual English & Spanish or Creole.
• State-approved license and registration as a nurse (RN, LPN, or LVN)

AND

• 2+ years’ experience working for a Health Plan in reviewing medical records for data collection, data entry, abstraction, overreads and chart collection activities that close gaps in care.

OR

• 2+ years of experience working with HEDIS/STAR measures.
• 2 or more years of HEDIS experience working in a physician, provider, and/or medical office.
• Two (2) or more years of experience proficiency in using electronic medical record (EMR) systems and other healthcare management software. Required.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook). Required.
• ICD 9/10 and CPT coding experience. Required.
• Excellent verbal communication skills with a customer-focused approach.

Preferred qualifications:

• Licensed Vocational/Registered Nurse.

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Interacts with patients, family members, staff, visitors, government agencies, etc, under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or listen. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

• Duties accomplished at the end of the day/month.
• Attendance/punctuality.
• Compliance with Company regulations.
• Safety and Security.
• Quality of work.

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple, competing tasks and demands and to seek supervisory assistance as appropriate.