HEDIS Reviewer

Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.

JOB SUMMARY:

The HEDIS Reviewer is responsible for supporting the overall direction, coordination and implementation of the HEDIS Medical Record Review process for Centers Plan for Healthy Living (CPHL) under the direction of the Director of Quality Management. Responsibilities include, but are not limited to coordination of outreach efforts to secure clinical documentation from Providers, reviewing and abstracting data from electronic and/or paper medical records for the annual HEDIS project according to strict HEDIS measure specifications. Documentation of all HEDIS data items into software in a timely manner. Representing CPHL and performing duties in a professional manner as well as utilizing time and resources efficiently. 

PRIMARY RESPONSIBILITIES: 

• Provide ongoing support relative to HEDIS data extraction, data collection and validation.
• Assist in coordination of outreach efforts to request, collect, and secure clinical documentation from Primary Care Physician (PCP) and/or Specialist(s) as indicated by HEDIS measures.
• Review assigned medical records in order to abstract specified and required clinical data elements for HEDIS reporting.
• Assist with ensuring that the medical record collection, review, and abstractions are complete and compliant in accordance with NCQA HEDIS technical specifications and guidelines.  
• Assist with HEDIS audits conducted in-house and at provider offices; and provide feedback on documentation and medical record coding.
• Responsible for performing accurate and comprehensive reviews of medical records using CPHL’s medical abstraction tool and software, while maintaining HIPAA Privacy and Security standards.
• Must successfully complete the training program offered, and meet & maintain competency and acceptable performance goals.
• Other duties and responsibilities, as assigned

Certifications/Licensure:

• Licensed LPN/ Coder / RN / Medical Records Retriever

Type of Experience                                          

Required:   

A minimum of three (3) years of experience in the health care industry, in HEDIS and/or quality improvement. Experience in a managed care health services environment. Demonstrated knowledge of data collection, medical record review, and data extraction. NCQA and HEDIS experience.

Specific Technical Skills

• Proficient use of MS Office with a focus on Excel, and Report writing software
• Knowledge of Clinical Software applications

Knowledge and Skills:

• Excellent communication, organization and writing skills
• Ability to effectively prioritize work, multi-task, and achieve goals on time; work independently and to self-motivate.
• Ability to work effectively and collaboratively with internal and external stakeholders
• Knowledge of and skills in data collection, analysis and presentation
• Excellent oral and written communication skills  
• Must demonstrate integrity, sound judgment and strong interpersonal skills. Must be able to address quality issues with tact and diplomacy
• Proficiency in use of Electronic Medical Records and Computer applications

SCOPE INFORMATION

# Direct Reports: None                              

PHYSICAL REQUIREMENTS:

The physical requirements 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.

• Duties are performed primarily in an office setting
• Regional travel involved

The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.  They should not be construed as an exhaustive list of all responsibilities, duties and skills required.

Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.