Job Description

Your Role

The Clinical Quality Team is responsible for reviewing and abstracting medical records to capture data and to ensure accuracy and completeness. The Clinical Quality Reviewer – Nurse, Senior will report to the Manager, Clinical Quality Analytics. In this role you will be reviewing medical records to support HEDIS and other regulatory audits. This role will require the ability to train others on HEDIS specifications and guidelines. This role will research and create medical record review reports and interpret findings.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Analyze quality issues from both internal and external sources. Determinates level of severity.
• Train internal staff as needed
• Be participating in regulatory audits as needed
• Be responsible for working with appropriate departments in the areas of compliance, process improvement, and member/provider satisfaction for all product lines. Reviews, research and responds to customer complaints relating to quality of medical care and service. Recommends and/or implements process improvements related to the potential quality of medical care and service.
• Review medical records and documents to abstract clinical data for HEDIS and other audits while identifying opportunities for process improvements
• Meet daily abstraction and overread goals while maintaining a high accuracy percentage
• Train and advise healthcare professionals and contingent staff on HEDIS and other audit regulatory compliance
• Support collection of medical records and reports

Your Knowledge and Experience

• Requires current CA RN license
• Bachelor of Science in nursing or advanced degree preferred
• Requires a minimum of 5 years of prior relevant experience
• Experience in HEDIS medical record review required
• Requires experience in Excel and HEDIS audits
• Desired experience and knowledge of medical record systems and processes
• Desired knowledge and familiarity in EMR software such as Epic, EClinical Works, Allscripts, NextGen, etc.
• Desired knowledge of ICD-10, CPT, and other modifier codes

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.