Clinical Medical Review Nurse

Job Title : Clinical Medical Review Nurse Location : Maryland, Virginia and D.C. Type : Contract Compensation : $41.50 Contractor Work Model : Hybrid The Clinical HEDIS Nurse (Medical Review Specialist) is responsible for supporting the organization’s HEDIS and Quality initiatives through medical record retrieval, clinical data abstraction, and quality review processes in alignment with NCQA specifications. This role demands significant expertise in HEDIS measures, EMR navigation, and clinical abstraction. The nurse must maintain strict adherence to HIPAA Privacy and Security standards and demonstrate a strong commitment to data accuracy, quality improvement, and timely execution. Candidates must hold an active RN or LPN license. Work Arrangement This is a hybrid role, with a combination of remote work and potential on-site requirements based on operational needs. Key Responsibilities Contact provider offices to request or validate facility and provider contact information specifically for HEDIS medical record retrieval. Retrieve and upload medical records from electronic medical record (EMR) systems in accordance with HIPAA requirements and HEDIS guidelines. Abstract clinical data from medical charts accurately and efficiently using proprietary abstraction platforms and following company-specific training and NCQA specifications. Use internal systems to create, track, and research clinical and retrieval pends to support overall HEDIS operations. Document all communications, record retrieval activities, and chart status updates in designated systems. Assist with outreach and coordination efforts to maximize medical record collection efficiency and compliance. Additional Responsibilities (assigned based on experience and skill set) Overreading : Review and validate abstracted charts completed by other team members for accuracy and adherence to HEDIS guidelines. Correct errors identified during overread and conduct additional chart reviews when similar errors are found. Collaborate with abstractors to provide feedback and re-education when necessary. Risk Adjustment & Off-Season Support : Support medical record retrieval activities for risk adjustment, supplemental data validation (PSV), and various other quality and HEDIS-related initiatives outside of the core season. Qualifications Education : Degree in Nursing (Associate’s, Diploma, or Bachelor’s) Credentials such as RHIA, RHIT, or a related field preferred Licensure : Active RN or LPN license is required Experience : At least 3 years of clinical nursing experience Minimum of 5 years of HEDIS experience in a health plan or vendor setting Strong understanding of NCQA quality metrics Experience with HEDIS abstraction software or tools (e.g., Reveleer, Cotiviti, Inovalon) preferred Technical Skills : Proficiency in Microsoft Office applications (Excel, Word, PowerPoint, Outlook, Teams) Experience with multiple EMR systems, including Epic, eClinicalWorks, Athena, Cerner, AllScripts, and Tebra Core Competencies : Strong attention to detail and analytical thinking High degree of accuracy in data interpretation and entry Excellent time management and organizational skills Ability to work independently and collaboratively in a fast-paced environment Professional communication skills, both written and verbal Work Environment Hybrid work model (remote and occasional in-office work as needed) Requires prolonged periods of sitting and working on a computer Frequent phone interaction with provider offices may be required System One, and its subsidiaries including Joulé, ALTA IT Services, and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan. System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law. #M2 #LI-AJ1 #DI- Ref : #850-Rockville (ALTA IT)