Hedis Review Nurse Jobs in the United States
Kinetic Personnel Group
Ontario, CA
Requirements: 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. 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.
Lumen Solutions Group, Inc.
Baltimore, MD
We provide a wide array of experienced business and IT professionals supporting clients from solution design to implementation and support. We specialize in professional IT consulting services, IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, Enterprise Transformation.
Kinetic Personnel Group
Ontario, CA
The HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. A permanent position does include excellent retirement pension (CalPERS), ~10% yearly bonus, 6% contribution 453b and excellent government benefits including a generous Holiday/PTO schedule.
TravelNurseSource
$2364.48
Everett, WA
Guaranteed Hours: 72 hours per 2 week periodHospital Highlights Type of Facility: Level II Trauma CenterTotal Staffed Beds: 571 total for both campusesScrub Color: Any (no reddish orange permitted)Charting: EPICParking Cost: Facility Paid Modified 7:00:00 AM Account Manager: Leilani Bowman Account Manager Email: COVID-19 Vaccine: Not Required Flu Vaccine: Unknown Job Requirements & Qualifications Previous Charge Experience : - Years of Experience : 1 Patient Ratio Experience : Charting System Experience : Required Charting System Name : Any Community Hospital Experience : - LTAC Experience : - Trauma Level I Experience : - Trauma Level II Experience : - Travel Experience Required : - Certifications : BLSSkills : Acute Hospital, Long Term Acute Care/Rehab/Skilled Nursing, Concurrent Review, Continued Stay Reviews, Retrospective Review, Utilize InterQual Criteria, Utilize Milliman Guidelines, CMS: Centers for Medicare and Medicaid Services, CPT (Current Procedural Terminology) coding and billing, Department of Health, DRG (Diagnosis Related Groups), HEDIS (The Healthcare Effectiveness Data and Information Set) Measures, HIPAA guidelines (Health Insurance Portability and Accountability Act), ICD 10 Coding, NCQA (National Committee for Quality Assurance), OSHA, The Joint Commission/ Core Measure/National Safety Goals, Workers Compensation Unit Details Staffing & Scheduling Scheduling Type : - Patient Ratios Days : - Patient Ratios Nights : - Patient Ratios Weekends : - Float Required : - Call Required : - Weekend Coverage : - Number of Weekend Shifts Per Contract : - Pre-Approved Time Off : - Orientation Hours : - Facility & Patient Care Details Patient Age Groups : - Daily Census : - Number of Visits Per Day : - Number of Rooms : - Number of Beds : - Additional Unit Information Interdisciplinary Support : - Patient Diagnoses : - Special Procedures/Unit Details : - Special Equipment : - #Tier3 Travel Compliance SSN DOB RTO: Aya Offer: 5 Days. Over 20 hours requires PM approval Modules are completed pre-start, and annually Time spent on modules is self-reported, completion is recorded in Workramp transcripts Submittal Details: #Tier3 Travel ComplianceSSNDOBRTO: Aya Offer: 5 Days.
VNS Health
$109900 - $146500
Brooklyn, NY
Manages and provides comprehensive, advanced nursing care, including post-discharge aftercare visits, annual comprehensive assessment visits, palliative care-care management program onboarding, and change in condition assessment visits (including physical examination, comprehensive history, screening for physical and/or psychological conditions, and point of care testing). Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.
CenterWell Senior Primary Care
$246100 - $344200
North Myrtle Beach, SC
Ensure clinicians effectively co-manage high-risk episodes of care and patients with partnered Care Integration Team (CIT) resources and programs for transitions of care management (TCM), high-risk patient management (HRPM), and social determinants of health (SDOH) efforts, improving clinical outcomes and avoidable utilization. Personally deliver high-quality primary care and demonstrate a high degree of patient care ownership and clinical excellence in age-friendly senior primary care including health promotion & prevention, disease management, effective specialist & hospital co-management, and complex care management.
TravelNurseSource
$2369
San Pedro, CA
CASE MANAGEMENT EXPERIENCE IN CALIFORNIA REQUIRED, PLEASE SCREEN IF THEY DO NOT HAVE THIS, DO NOT PASS Float: n/a CA state license: Yes Pending License accepted: No RTO Restrictions: No more than 7 daysHospital Highlights Type of Facility: acute care Scrub Color: Modified 7:00:00 AM Account Manager: Jordan Hinojos Account Manager Email: COVID-19 Vaccine: Not Required Flu Vaccine: Unknown Job Requirements & Qualifications Previous Charge Experience : - Years of Experience : 2 Patient Ratio Experience : Charting System Experience : Required Charting System Name : Epic Community Hospital Experience : Required LTAC Experience : - Trauma Level I Experience : - Trauma Level II Experience : - Travel Experience Required : Yes Certifications : Skills : Acute Hospital, Admission Criteria, Admission Criteria, Benefits Eligibility, Care coordination, CMS: Centers for Medicare and Medicaid Services, Concurrent Review, Concurrent Review, Continued Stay Reviews, Continued Stay Reviews, CPT (Current Procedural Terminology) coding and billing*, Department of Health, Determine Medical Necessity per Evidence-Based Guidelines, Disability case management, Discharge Planning, Disease management, DRG (Diagnosis Related Groups), Emergency Department, HEDIS (The Healthcare Effectiveness Data and Information Set) Measures*, HIPAA guidelines (Health Insurance Portability and Accountability Act), ICD 10 Coding*, ICU, Medical Necessity, MS, NCQA (National Committee for Quality Assurance)*, Needs Assessment/ Order DME, OSHA*, Plan of Care, Pre-Cert Review*, Prior Authorization, Prior Authorizations, Retrospective Review*, Retrospective Review*, The Joint Commission/ Core Measure/National Safety Goals, Utilize InterQual Criteria, Utilize InterQual Criteria, Worker s comp case management*, Workers Compensation, CA experience in Case Management Unit Details Staffing & Scheduling Scheduling Type : self Patient Ratios Days : 15 Patient Ratios Nights : 45 Patient Ratios Weekends : 25 Float Required : - Call Required : - Weekend Coverage : True Number of Weekend Shifts Per Contract : - Pre-Approved Time Off : one Orientation Hours : 40 Facility & Patient Care Details Patient Age Groups : Adults, Geriatrics Daily Census : 50-55 Number of Visits Per Day : - Number of Rooms : 82 Number of Beds : 82 Additional Unit Information Interdisciplinary Support : Interpretation Services, Social Services Patient Diagnoses : **HARDSTOP-Acute care hard stop- must have-MS, MS/tele and ICU and some ER**HARDSTOPS**Care Coordination, Utilization Review,discharge planning, Interqual and Epic are all HARDSTOPS CASE MANAGEMENT EXPERIENCE IN CALIFORNIA REQUIRED, PLEASE SCREEN IF THEY DO NOT HAVE THIS, DO NOT PASS Special Procedures/Unit Details : REQUIRED: Admission Criteria (InterQual), (MCG in NorCal) If clinician does not have experience in CA as a Case Manager, please Screen for manager to review. Over 20 hours requires PM approval Modules are completed pre-start, and annually Time spent on modules is self-reported, completion is recorded in Workramp transcripts Submittal Details: #Tier3 Travel ComplianceWe must have these three things before your traveler can be reviewed by our clinical team so please submit with this information is their upcoming interview availability?.Please confirm the DOB and full SSN is correct in Connect.
Mercy
$65000 - $78000
Springdale, AR
Attention to detail and accuracy knowledge of the Internet, evidence-based medicine, good clinical inquiry and investigational aptitude Proficiency in MS Office (Word, Excel, and PowerPoint) Strong public speaking skills and demonstrated ability in presenting to a variety of co-workers, including physicians, clinicians, administration, and support staff self-directed and able to perform independently with minimal oversight, ability to travel throughout the hospital. The Cardiac Quality Improvement Specialist partners with leaders and multidisciplinary teams to drive high‑impact cardiac quality initiatives, modeling and teaching improvement principles while developing project plans, conducting chart audits, and analyzing outcomes against national benchmarks.
TravelNurseSource
$2712.46
Santa Barbara, CA
Case Management/Utilization ReviewAdmission Criteria RequiredCare coordination RequiredDischarge Planning RequiredUtilize InterQual Criteria RequiredUtilize Milliman Guidelines RequiredUtilization ReviewAdmission Criteria RequiredAppeals and Denials RequiredConcurrent Review RequiredContinued Stay Reviews RequiredMedical Necessity RequiredRetrospective Review RequiredUtilize InterQual Criteria RequiredUtilize Milliman Guidelines RequiredREGULATORYCMS: Centers for Medicare and Medicaid Services RequiredCPT (Current Procedural Terminology) coding and billing RequiredDepartment of Health RequiredDRG (Diagnosis Related Groups) RequiredHEDIS (The Healthcare Effectiveness Data and Information Set) Measures RequiredHIPAA (The Health Insurance Portability and Accountability Act) RequiredICD 10 Coding RequiredNCQA (National Committee for Quality Assurance) RequiredOSHA: Occupational Safety and Health Administration RequiredThe Joint Commission/ Core Measure/National Safety Goals RequiredWorker s Compensation Required Modified 7:00:00 AM Account Manager: Laura Kremicki Account Manager Email: COVID-19 Vaccine: Required + Booster - Medical/Religious Exemptions only Flu Vaccine: Required - Medical/Religious Exemptions and Declinations Allowed Job Requirements & Qualifications Previous Charge Experience : - Years of Experience : 2 Patient Ratio Experience : Charting System Experience : Required Charting System Name : Epic Community Hospital Experience : - LTAC Experience : - Trauma Level I Experience : Preferred Trauma Level II Experience : Preferred Travel Experience Required : Yes Certifications : BLSSkills : Acute Hospital, Long Term Acute Care/Rehab/Skilled Nursing, Admission Criteria, Care coordination, Discharge Planning, Utilize InterQual Criteria, Utilize Milliman Guidelines, Admission Criteria, Appeals and Denials, Concurrent Review, Continued Stay Reviews, Medical Necessity, Retrospective Review, Utilize InterQual Criteria, Utilize Milliman Guidelines, CMS: Centers for Medicare and Medicaid Services, CPT (Current Procedural Terminology) coding and billing, Department of Health, DRG (Diagnosis Related Groups), HEDIS (The Healthcare Effectiveness Data and Information Set) Measures, HIPAA guidelines (Health Insurance Portability and Accountability Act), ICD 10 Coding, NCQA (National Committee for Quality Assurance), OSHA, The Joint Commission/ Core Measure/National Safety Goals, Workers Compensation Unit Details Staffing & Scheduling Scheduling Type : block Patient Ratios Days : - Patient Ratios Nights : - Patient Ratios Weekends : - Float Required : When needed Call Required : N/A Weekend Coverage : - Number of Weekend Shifts Per Contract : - Pre-Approved Time Off : - Orientation Hours : - Facility & Patient Care Details Patient Age Groups : Adults Daily Census : 30 Number of Visits Per Day : 18 Number of Rooms : 30 Number of Beds : 32 Additional Unit Information Interdisciplinary Support : Interpretation Services, Social Services, Transportation Patient Diagnoses : - Special Procedures/Unit Details : For this role, we need someone actively functioning as an RNCM, with hands-on experience in inpt care coordination. Special Equipment : - #Tier1 Travel Compliance Compliance document deadline is the Wednesday prior to start at 5:00pm PST RTO required with submittal License in hand required with submittal Modules: Modules are not required Submittal Details: #Tier1 Travel ComplianceCompliance document deadline is the Wednesday prior to start at 5:00pm PSTRTO required with submittalLicense in hand required with are not required Guaranteed Hours: Contract Weeks:91
TravelNurseSource
$2640
Irvine, CA
TravelNurseSource is working with Lancesoft Inc to find a qualified Case Manager RN in Irvine, California, 92650! Collaborate with interdisciplinary teams and communicate with payers/patients.
VNS Health
$85000 - $106300
New York, NY
Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond. Collaborates across departments—including Care Management, Utilization Management, Provider Relations, Compliance, and Analytics—to sustain continuous improvement, advance health equity, and ensure regulatory readiness.
Campbell County Health
Gillette, WY
Our organization includes Campbell County Memorial Hospital, a 90-bed acute care community hospital in Gillette; Campbell County Medical Group, featuring nearly 20 specialty and primary care clinics—including locations in Wright and Hulett; and The Legacy Living & Rehabilitation Center, a long-term care facility. Utilizes risk mitigation strategies by assisting and supporting process improvement projects and event analysis which may include RCAs, FMEAs, investigations, and medical record reviews.
The Village Health & Rehabilitation
$35 - $39.5
Missoula, MT
Riverside Health & Rehabilitation skilled nursing community offers 193 skilled nursing beds and provides the support residents and patients need through a wide range of skilled nursing care, restorative therapies and memory care. The QIC assists the leadership team in assessing, planning, implementing and evaluating quality programs and structuring learning experiences as a part of the improvement process.
ChristianaCare
$121180.8 - $193897.6
Newark, DE
Incredible Work/Life benefits including annual membership to care.com, access to backup care services for dependents through Care@Work, retirement planning services, financial coaching, fitness and wellness reimbursement, and phenomenal discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets and much more! This is a high-visibility, enterprise-impact role designed for a professional who thrives in influence-based leadership—driving outcomes across multiple oncology programs without direct reports, but with significant responsibility for program oversight, regulatory readiness, and performance improvement.
HarmonyCares
Elyria, OH
The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity. Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.).
HarmonyCares
Ostrander, OH
The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity. Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.).
HarmonyCares
Germantown, TN
The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity. With 37 Medical Group teams across 14 States and growing, we are the leading national VBC organization with a continuum of care services achieving high quality outcomes maintaining top performing #2 position as an ACO REACH.
HarmonyCares
Cleveland, OH
The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity. Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.).
HarmonyCares
Delaware, OH
Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.) Develop and participate in APP clinical development (Evidenced based care, professionalism, etc.) Lead and participate in high-risk huddles and ensure all patients discussed have a plan of care documented and includes all care management team members Build team-based culture and work collaboratively with clinical team members Conducts 10 chart audits per month or per state regulations, whichever is higher Act as resource for clinical team members for patient care questions/concerns and participate in difficult conversations with patients/family members as requested by team Routinely conduct panel reviews with APPs Sign DME, death certificates, and other orders as needed on behalf of APP (as regulated by state) Frequently review Quality metrics, pod level performance and identify areas for improvement leading to superior Quality (HEDIS) performance Frequently review clinician capacity and productivity performance. Partner with Site Medical Directors to develop countermeasures and support their implementation when provides are off track Work collaboratively with Regional Medical Director (RMD) to identify opportunities for care improvement Assists with service inquiry, resolution of patient complaints and requests for Pod as needed Assist pod providers to achieve higher EMR efficiency Participate in patient care to assigned panel and other patients as needed (High risk or complex patients, Physician face to face requirements, cognitive assessments, etc.) Participate and lead clinical education regarding accurate diagnosis, documentation and management of chronic conditions Assist with compliance and HR resolutions Responsible for discipline actions and performance reviews for direct reports Additional duties as assigned by the Regional Medical Director as related to clinical pod performance and outcomes.
HarmonyCares
Berwyn, PA
Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.) Develop and participate in APP clinical development (Evidenced based care, professionalism, etc.) Lead and participate in high-risk huddles and ensure all patients discussed have a plan of care documented and includes all care management team members Build team-based culture and work collaboratively with clinical team members Conducts 10 chart audits per month or per state regulations, whichever is higher Act as resource for clinical team members for patient care questions/concerns and participate in difficult conversations with patients/family members as requested by team Routinely conduct panel reviews with APPs Sign DME, death certificates, and other orders as needed on behalf of APP (as regulated by state) Frequently review Quality metrics, pod level performance and identify areas for improvement leading to superior Quality (HEDIS) performance Frequently review clinician capacity and productivity performance. Partner with Site Medical Directors to develop countermeasures and support their implementation when provides are off track Work collaboratively with Regional Medical Director (RMD) to identify opportunities for care improvement Assists with service inquiry, resolution of patient complaints and requests for Pod as needed Assist pod providers to achieve higher EMR efficiency Participate in patient care to assigned panel and other patients as needed (High risk or complex patients, Physician face to face requirements, cognitive assessments, etc.) Participate and lead clinical education regarding accurate diagnosis, documentation and management of chronic conditions Assist with compliance and HR resolutions Responsible for discipline actions and performance reviews for direct reports Additional duties as assigned by the Regional Medical Director as related to clinical pod performance and outcomes.
HarmonyCares
Norfolk, VA
The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity. As a Physician Leader, you will have clinical oversight of 4-5 Advance Practice Providers, dividing the week 2.5 days of admin/clinical oversight + 2.5 days hands on patient care with a small panel of 140 patients.
HarmonyCares
Bedford, OH
The Medical Pod Leader will be the clinical leader responsible for the clinical performance of clinical pod team members – to include: Accurate diagnosis and documentation, quality, patient experience, affordability, patient safety, clinical team dynamics, and provider productivity. Collaborate with clinical team members associated with pod (Community Health Workers, Medical Social Workers, Nurse Navigators, Care Managers, Patient Care Coordinators, etc.).
Conviva Care Center
Deerfield Beach, FL
Graduate of accredited MD or DO program of accredited university Demonstrate a high level of skill with interpersonal relationships and communications with colleagues/patients Basic computer skills, including email and EMR This role is considered patient facing and is a part of CenterWells Tuberculosis (TB) screening program. Humanas Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating over 175 centers across eight states under two brands: CenterWell & Conviva.
CenterWell Senior Primary Care
Las Vegas, NV
If selected for this role, you will be required to be screened for TB Preferred Qualifications:Board Certification or Eligible to become certified (ABMS or AOA) in Family Medicine, Internal Medicine or Geriatric Medicine preferredActive and unrestricted DEA licenseMedicare Provider NumberMedicaid Provider NumberMinimum of two to five years directly applicable experience preferredExperience managing Medicare Advantage panel of patients with understanding of Best Practice in coordinated care environment in a value based relationship environmentKnowledge of Medicare guidelines and coverageBilingual is a plusKnowledge of HEDIS quality indicatorsAdditional Information:Guaranteed base salary + Quarterly BonusExcellent benefit package health insurance effective on your first day of employmentCME Allowance/TimeOccurrence Based Malpractice Insurance Humanas Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating over 175 centers across eight states under two brands: CenterWell & Conviva.
CenterWell Senior Primary Care
Las Vegas, NV
Humanas Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating over 175 centers across eight states under two brands: CenterWell & Conviva. Our model is positioned to provide higher quality care and better outcomes for seniors by providing a concierge experience, multidisciplinary services, coordinated care supported by analytics and tools, and deep community relationships.
CenterWell Senior Primary Care
Fort Worth, TX
Preferred Qualifications: Board Certification or Eligible to become certified (ABMS or AOA) in Family Medicine, Internal Medicine or Geriatric Medicine preferredActive and unrestricted DEA license Medicare Provider Number Medicaid Provider Number Minimum of two to five years directly applicable experience preferred Experience managing Medicare Advantage panel of patients with understanding of Best Practice in coordinated care environment in a value based relationship environment Knowledge of Medicare guidelines and coverageBilingual is a plusKnowledge of HEDIS quality indicators. Humanas Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating over 175 centers across eight states under two brands: CenterWell & Conviva.
Conviva Senior Primary Care
West Palm Beach, FL
Humana’s Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating multiple centers across eight states under two brands: CenterWell & Conviva. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients.
Cambia Health Solutions
Bellevue, WA
The HEDIS Medical Record Analyst's primary responsibilities will be to retrieve, abstract, or overread medical records in order to capture pertinent, required, data elements for HEDIS reporting. Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history.
Alura Workforce Solutions
$30.72
Rancho Cucamonga, CA
REQUIREMENTSThree (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. 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.
Alura Workforce Solutions
Rancho Cucamonga, CA
REQUIREMENTSThree (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. 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.
Alura Workforce Solutions
Rancho Cucamonga, CA
REQUIREMENTSThree (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. 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.
Alura Workforce Solutions
Rancho Cucamonga, CA
REQUIREMENTSThree (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. 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.
Alura Workforce Solutions
Rancho Cucamonga, CA
REQUIREMENTSThree (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. 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.
Alura Workforce Solutions
Rancho Cucamonga, CA
Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.
Alura Workforce Solutions
Rancho Cucamonga, CA
Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.
Alura Workforce Solutions
Rancho Cucamonga, CA
Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.
Alura Workforce Solutions
Rancho Cucamonga, CA
Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.
Central Health
Austin, Texas
Utilizes clinical skills to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care for members that are hospitalized in acute, skilled and long-term care settings. Overview: Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time.
CINQCARE
$95000 - $120000
WASHINGTON, DC
This role ensures technical excellence, regulatory compliance, audit readiness, and timely submissions in accordance with the National Committee for Quality Assurance (NCQA), Centers for Medicare & Medicaid Services (CMS), and the Executive Office of Health and Human Services (EOHHS). The Manager drives quality performance improvement, optimizes pay-for-performance outcomes (e.g., Medicare Stars and Quality Withhold), oversees electronic clinical data integration, and works in a matrix environment with a multidisciplinary analytics team.
HJ Staffing
Philadelphia, PA
Working under the direction of the Manager of Medical Record Review Operations, you will be responsible for performing medical record abstraction and overread in support of Quality reporting (annual HEDIS and State EQRO). Data Management: Utilize specialized software applications to accurately enter chart audit results into the database and provide real-time feedback.
Lumen Solutions Group Inc
Baltimore, MD
Role: Clinical Medical Review Nurse Location: Canton, MD (Hybrid – 2–3 days onsite per week) Type: Contract About the Role: We are seeking Licensed Practical Nurses (LPN) or Registered Nurses (RN) to join the Quality team as Clinical Medical Review Nurses. This is a hybrid contract position requiring both remote work and regular onsite presence at the Canton, MD office.
Northwest Permanente
Portland Metro Area, Oregon
Northwest Permanente is a self-governed, multi-specialty group of 1,500 physicians, clinicians, and administrative professionals caring for 630,000 members in Oregon and Southwest Washington. Overview: The Medical Review Nurse serves as a clinical resource for Northwest Permanente (NWP) physicians by supporting the completion of medical certifications for serious health conditions requiring employment leave.
Hackensack Meridian Health
Edison, New Jersey
Responsibilities: A day in the life of a nurse (RN) at Hackensack Meridian Health includes: Effective provides/facilitates the following education & advocacy support: Education: Complete needs assessment, formulate and carry out a comprehensive teaching program -Promotes patient engagement, self-management, and shared decision making -Establishes relationship with patients and caregiver, if any -Translate care choices and treatment plans . Identify high-risk patients, assess clinical and psychosocial needs, make referrals to ancillary providers (disease management, pharmacy, social work, palliative care, community-organizations, non-clinical services), develop care plan in coordination with PCP, engage and activate patients .
Hackensack Meridian Health
Tinton Falls, New Jersey
Responsibilities: A day in the life of a RN, Community Based Care Management at Hackensack Meridian Health includes: Works closely with physicians in all specialties to develop and execute patient care plans and coordinate communications & referrals with care team members & settings of care on behalf of patients. The RN, Community Based Care Management provides direct support to physician practices and identifies complex patients or patients with targeted conditions who require care management, coaching, education, supervision, and/or support.
UnitedHealth Group
$20.38 - $36.44
Eden Prairie, MN
This role evaluates the quality and completeness of clinical documentation, by performing quality medical record reviews, assisting in the improvement of the clinical documentation process, maintaining accurate records of review activities, ensuring all data submitted to the health plan meets the HEDIS/Star technical specifications for medical records. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._.
Elevance Health
San Juan, PR
Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Inland Empire Health Plan
$91249.6 - $120910.4
Rancho Cucamonga, California
Reporting to Director of Hospital Relations, the Quality Improvement, RN will facilitate quality improvement initiatives across the continuum of care (i.e. acute care hospitals, skilled nursing facilities, hospice agencies, etc.) to enhance the overall quality of care delivered to members. Coordinate activities to foster good working relationships with contracted hospitals, skilled nursing facilities, hospice agencies, providers, and other external partners to encourage their participation in quality improvement groups.
Partnership HealthPlan of California
$103059.95 - $133977.94
Fairfield, California
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. Provider Preventable Conditions (PPCs) and ensures that appropriate notification is sent. to appropriate Partnership departments and DHCS Audits & Investigations Unit (A&I).
VNS Health
$93400 - $116800
New York, New York
Ensures Quality Improvement programs are aligned with CMS Triple Aim framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. This is an opportunity to apply your clinical expertise beyond bedside care, leveraging your knowledge to influence system-wide improvements, enhance compliance, and protect member safety at scale, while benefiting from the flexibility of a hybrid role.
UnitedHealth Group
$109500 - $164000
Elyria, OH
For NPs: Graduate of an accredited master's degree in nursing (MSN) program and board certified through the American Academy of Nurse Practitioners (AANP) or the American Nurses Credentialing Center (ANCC), Adult-Gerontology Acute Care Nurse Practitioners (AGACNP), Adult/Family or Gerontology Nurse Practitioners (AGPCNP, AGACNP, or ACNP), with preferred certification as ANP, FNP, or GNP. Dedicated to improving the health and well-being of patients, this position collaborates with the PCP, HBMC interdisciplinary teammates and consultants, and as needed, the health plan Medical Director and other health professionals, to develop and carry out patients' goals of care in all phases of the patient journey.