HEDIS Quality Improvement Nurse

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work. 
• Reduce health disparities. 
• Become an anti-racist organization. 
• Create an equitable work environment. 

About the Role

The HEDIS Quality Improvement Nurse is responsible for performing medical record review audits and analysis for regulatory National Committee for Quality Assurance (NCQA) and Centers for Medicare & Medicaid Services (CMS) audits. This role supports assisting the Manager with developing provider audit reports, provider education, identifying opportunities for process improvement, performs overread and peer review of other team member output.

To be successful in this role, you:

• Are a Licensed Registered Nurse (RN) or License Practical Nurse (LPN).
• Have a minimum of five (5) years combined experience performing NCQA, Health Effectiveness Data and Information Set (HEDIS) and CMS Medicare Star measure medical record and coding review AND conducting documentation and coding
•  Have experience with Microsoft Office Suite (Word, Excel, Outlook, and Internet Explorer) and Adobe Acrobat, including comfort with pivot tables at a minimum. Experience with SharePoint, Confluence, and Smartsheet is advantageous.
• Have bachelor’s degree in nursing or an equivalent combination of education and highly relevant experience preferred.
• Have knowledge and experience with NLP, computer assisted medical record review and coding applications (preferred).
• Have an applied understanding of principles of reimbursement-based CMS Medicare Stars and State Value Base program experience preferred.

Essential functions and Roles and Responsibilities:

• Support updating and maintaining CHPW HEDIS medical record review and coding guidelines to reflect changes of the NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes. Interpret changes and support modifying CHPW policies in coordination with HEDIS Performance Measurement Manager and HEDIS Program Manager.
• Keep current on regulatory, medical record documentation and coding issues/best practices including NCQA Guidelines for Medical Record Documentation, Coding and Reporting.
• Present findings via verbal and written updates to internal audiences including peer to peer, department leadership reporting, provider and clinical teams, and vendor support teams.
• Update and distribute provider feedback reports to HEDIS Performance Manager as needed for identifying provider performance trends and participate in creating materials for all significant audit findings including trends and associated recommendations (e.g., training, oversight, monitoring, process flow changes, documentation, and coding education) specific to internal departments, coding vendors, and others.
• Serve as medical record review and coding SME. Support overread and validation of other colleagues’ documentation performance.
• Complete the annual regulatory HEDIS medical record review and coding quality assurance process and workflow of the primary source validation and retrospective medical record and coding audit.
• Identify and implement practices and Quality Assurance process improvement
• Monitor and comply with internal medical record and coding guidelines, department policies, and NCQA/CMS quality program guidelines, rules, and regulations.
• Continuous development of knowledge in Medicare, Medicaid, and Exchange programs to ensure timely review of regulatory medical record documentation and coding best practices including NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes.
• Support chart audit processes, including provider and vendor documentation of required medical record documentation and coding to ensure adherence with NCQA HEDIS and CMS Medicare Stars guidelines.
• Act as a liaison between internal departments on regulatory data validation audits (including Primary Source Validation, Prospective Medical Record Review and Retrospective (Hybrid) Medical Record Review.).
• Perform root cause analysis to identify issues that may contribute to medical record documentation and coding
• Perform internal and external coding quality reviews to validate correct medical record documentation and coding
• Ot