HEDIS Clinical Review Nurse, LVN 25-00492

1. Interpret, clarify, and implement changes accurately through the maintenance of current knowledge of HEDIS technical specifications
2. Demonstrate the ability to accurately apply technical specifications when performing chart reviews and communicate changes and clarifications to impacted business units within the organization, as appropriate to perform the primary function of medical record validation and support education/ outreach based on required NCQA standards
3. Support outreach and education projects related to HEDIS, Supplemental Data, and other quality improvement initiatives. Research and develop training materials, conduct presentations and information sessions, or provide targeted outreach about Historical Supplemental Data, NCQA HEDIS Technical Specifications, and other quality activities/medical record review projects
4. Act as a liaison between the Quality Improvement/HEDIS department and other departments, practitioners, and providers in support of HEDIS-related programs and activities
5. Collaborate with HEDIS improvement Nurse to develop and conduct HEDIS trainings to IEHP departments and Providers in support of IEHP's Quality Programs and goals
6. Review medical record submissions for supplemental data, in support of IEHP's audit standards and requirements for HEDIS reporting
7. Review all medical record abstractions with a high attention to detail to ensure IEHP is compliant with the high-quality standards set for HEDIS medical record audits
8. Participate in medical record abstraction and accuracy validations (overreads) for various HEDIS efforts, such as the annual hybrid pursuit, prospective chart reviews, and other quality improvement project reviews
9. Appropriately escalate quality assurance concerns to HEDIS RN or CQI Supervisor for final determination of NCQA or HEDIS compliance

• Three (3) or more years in healthcare administration in the areas of Utilization Management, Care Management, Quality Improvement or Quality Assurance, where medical record review, preferably in an HMO or managed care setting, is required
• Minimum one (1) year clinical experience in an acute care facility, skilled nursing facility, home health or clinic setting required
• High School Diploma or GED required
• Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

• Must have valid California Driver's License
• Working knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes
• Computer applications, including word processing, database, and spreadsheets
• Proficient in Microsoft Office Suite. Excellent interpersonal/communication skills
• Strong attention to detail
• Ability to handle multiple projects and strong problem-solving capability