HEDIS Review Nurse

SUMMARY DESCRIPTION: An RN and LPN(LVN) responsible for annual patient chart inspection/audit. Audits are conducted to ensure that providers (MDs) accepting insurance are in compliance with standards of patient care set forth by the insurance company. Experience with medical record review required.
ESSENTIAL FUNCTIONS:
1. Apply structured auditing criteria to abstract medical records, follow defined procedures for saving approved medical record documentation and accurately enter the results of chart audits into the healthplans database, Quality Spectrum Hybrid Reporter (QSHR).
2. Abstract medical record documentation submitted for HEDIS measures, used annually for reporting to National Committee for Quality Assurance (NCQA). The HEDIS measures are used to assist in measuring quality of health care provided to healthplan members.
3. Maintains productivity level with less than a 5% error rate in record abstraction and data entry on an ongoing basis.
4. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
5. Maintain complete confidentiality of company related business.
6. Maintain effective communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
JOB REQUIREMENTS:
? Registered Nurse (RN) with unrestricted license in state.
? Clinical experience.
? Experience in utilization review, quality assurance, and/or medical record and site review audits.
? Knowledge of medical terminology standard medical practices, formal quality improvement process, and federal, state, accreditation regulations and standards.
? Verbal and written communications skills including interpersonal skills for meeting with physicians and office staff and representing the company using diplomatic/professional demeanor.
? PC proficiency to include Word and Excel.