Clinical Medical Review Nurse

Our client, a Health Insurance company, is looking for a Clinical Medical Review Nurse for their Columbia, MD/Hybrid location.

Responsibilities:

• This role will support medical record retrieval, abstraction, pend management, overreads, and other key activities throughout the HEDIS project. The position will help enable the team to conduct the HEDIS Hybrid Project in-house.
• Additional support may include Risk Adjustment medical record retrieval, internal audits, and other identified operational needs.
• The Clinical Medical Review Specialist (a professional with clinical experience) will report to the Clinical Support Supervisor - HEDIS and be part of the Quality Team. The main duties include chart retrieval, using proprietary tools and software to conduct thorough medical record reviews in line with NCQA specifications, retrieval follow-up, and escalating issues as needed. Main duties will be assigned according to experience, knowledge, skills, and abilities. This role requires extensive knowledge of HEDIS measures to accurately and expediently abstract medical records, all while adhering to HIPAA Privacy and Security standards. Additional tasks involve helping with EMR Medical Record Retrieval for HEDIS, contacting provider offices to request or validate facility and provider contact information and record retrieval preference, and/or requesting medical records for the HEDIS project and supporting other needs within the Quality Department.

Requirements:

• 3 years of clinical experience and 5 years of HEDIS experience is required for RN's and LPN's. In lieu of a degree, candidates (CNA's) must have 10 years of relevant HEDIS abstraction and/or overread experience in a payer, health insurance, or HEDIS vendor environment
• Candidates must be detail-oriented, able to work independently, and maintain a high level of accuracy. Required technical skills include proficiency with Microsoft Office, including Excel, Word, PowerPoint, Microsoft Teams, and Outlook. Experience retrieving medical records from EMR platforms such as Epic, eClinicalWorks, Athena, Cerner, Allscripts, and Tebra is essential. HEDIS overread experience with a health plan or HEDIS vendor is preferred
• Nursing license plus bachelor's degree in Nursing, Associate's degree in Nursing, or Diploma in Nursing is preferred.
• A nursing license is preferred but not mandatory. Candidates must complete training, pass test, and maintain satisfactory quality scores.
• We are seeking a qualified RN or LPN with experience supporting HEDIS reporting and abstraction processes in a payer, health insurance, or HEDIS vendor environment. The ideal candidate will understand NCQA healthcare quality metrics and have a proven ability to accurately abstract, interpret, and document medical record data for HEDIS gap closure
• Education Level: Bachelor's degree in Nursing, Associate's degree in Nursing, or Diploma in Nursing. In lieu of a degree, candidates must have 10 years of relevant HEDIS abstraction and/or overread experience in a payer, health insurance, or HEDIS vendor environment.
• Registered Health Information Associate/Registered Health Information Technician, Nursing, or a related clinical or healthcare field. Candidates qualifying in lieu of a degree must have 10 years of recent, directly relevant HEDIS medical record abstraction and/or overread experience within a payer, health insurance, or HEDIS vendor setting, including demonstrated knowledge of NCQA HEDIS specifications and abstraction platform workflows.
• 10 years of recent HEDIS abstractions / overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, Inovalon, Reveleer)
• Bachelor's degree in Nursing, Associates Degree in Nursing, Diploma in Nursing
• At least two recent consecutive HEDIS seasons with the same company.
• Current knowledge of clinical practices related to HEDIS and medical record review.
• Strong organizational skills, including the ability to prioritize responsibilities, maintain attention to detail, and shift tasks as needed.
• Experience using Microsoft Office applications, including Excel, Word, and PowerPoint, as well as web-based technology.
• Excellent verbal and written communication skills.
• Strong interpersonal skills, with the ability to work independently and as part of a team.

Why Should You Apply?

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities