HEDIS Clinical Review Nurse

Seeking a Medical Review Nurse for a 6 month contract position with our customer, a major Healthcare Insurance organization in the Maryland area.

The Medical Review Nurse handles day to day review of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and / or adjudication.

The incumbent will handle pre and post claim medical review for Commercial, FEP and Medicare Advantage Plans. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies.

Specifically, we are seeking candidates that are RN or LPN certified, and have specific knowledge with HEDIS medical chart review experience.

ESSENTIAL FUNCTIONS :

50% Accurately and efficiently over-read medical record abstractions performed by the HEDIS abstraction staff on a daily basis according to HEDIS specifications and company training guidelines.

Complete the over-read process in the Software Application, including comments if errors are found. Correct errors identified through over-read process, including a re-review of charts that may contain similar errors.

Identify and report abstraction errors and provide measure re-education with the abstractor. Utilizes various software applications to support HEDIS operations by entering data and / or changing chase status for the identified chase(s).

Maintains productivity level as determined by the QI Department. Maintain compliance with all HIPPA and member confidentiality requirements.

• 25% Medical Record Retrieval, Abstraction and Research during the Medical Record Review Project
• 25% Medical Record Retrieval for Risk Adjustment, internal Supplemental Data Audit (PSV) and other Quality and HEDIS related tasks in the off-season

This position is a hybrid opportunity, reporting to our clients office in Owings Mills or Canton MD, and possible providers offices in the Maryland area, 1-2x per month.

Required Skills

• RN or LPN certified is a required.
• Bachelor's or Associate-s degree in Nursing is highly preferred
• Experience : 1 year clinical experience, previous case management, discharge planning or utilization review experience.

Current knowledge of clinical practices and related medical policies.

Must have 5+ years of recent HEDIS abstractions / overreads experience in the payer / health insurance side of HEDIS or with a HEDIS vendor (ex.

Cotiviti, CareSeed, Inovalon, Reveleer) experience.

• Ability to effectively communicate and provide positive customer service to every internal and external customer
• Must have solid MS Excel knowledge
23 days ago