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HEDIS Registered Nurse

HEDIS Registered Nurse

Job Description

HEDIS - Registered Nurse

Seeking to hire a Registered Nurse with HEDIS and case management experience

  • Responsible for the review and resolution of clinical documentation, clinical complaints and appeals.
  • Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.
  • Requires an RN with unrestricted active license.
  • Fundamental Components & Physical Requirements include but are not limited to(* denotes essential functions)
  • Reviews complaint/appeal requests of all clinical and benefit documentation.
  • Considers all previous information as well as any additional records/data presented to render a recommendation/review.
  • Data gathering requires navigation through multiple system applications.
  • Contacts the provider of record, vendors or internal departments to obtain additional information.
  • Registered Nurse will accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand.
  • Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements and ERO eligibility which are required to support the appeals review.
  • Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements.
  • Condenses complex information into a clear and precise clinical picture while working independently.
  • Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs.
  • Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated. Exhibits the following Appeals Nurse Consultant Behaviors

    Job Requirements

    Job Requirements

    Required Education and Certification Requirements

    • RN with current unrestricted state licensure.

    Required Experience / Skills

    • Desired Managed Care experience preferred 3-5 years of clinical experience
    • Additional Information (situational competencies, skills, work location requirements, etc.)
    • Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

    Job Snapshot

    Employment Type Contractor
    Job Type Health Care
    Education Not Specified
    Experience Not Specified
    Manages Others No
    Relocation No
    Industry Healthcare - Health Services
    Required Travel Not Specified
    Job ID HEDIS_Philadelphia, PA
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    HEDIS Registered Nurse

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