Temporary Nurse HEDIS Reviewer

Position Summary

The HEDIS Nurse Reviewer is a registered nurse responsible for performing clinical reviews of healthcare data, focusing on HEDIS measures and quality improvement. This position requires strong clinical knowledge and expertise to accurately extract and audit patient data, ensuring it meets HEDIS standards. The HEDIS Nurse Reviewer participates in quality improvement initiatives and provides clinical insights to enhance healthcare outcomes and compliance with quality benchmarks.

Primary Duties and Responsibilities

• Performs clinical record reviews, data validations, and overreads to ensure accuracy and compliance with HEDIS measures.
• Develops reports to identify HEDIS care gaps and trends and work closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements.
• Conducts analysis to identify patterns, root causes, and opportunities for process and performance improvement.
• Supports Health Plan Quality programs and reporting for regulatory requirements (CMS, DHA, NCQA, etc.).
• Prioritizes reports according to business needs, regulatory requirements, urgency, and other key business factors.
• Assists in the coordination of outreach efforts as needed to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications.
• Identifies, collects, documents, and stores HEDIS data in accordance with standard operating procedures and HEDIS technical specifications.
• Applies clinical judgement to validate diagnosis, procedures, exclusions, and documentation elements.
• Educates non-clinical staff on HEDIS requirements and clinical relevance of data.
• Collaborates with physicians, office staff, and care teams to obtain medical records, support HEDIS quality initiatives, provide education on HEDIS measure requirements, documentation standards, and coding opportunities and facilitate timely gap closure activities.
• Maintains NCQA and other training requirements and meet productivity standards as directed by the HEDIS supervisor.
• Other duties and responsibilities, as assigned.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

Position Qualifications

Education