Clinical Quality Reviewer - Nurse, Senior

Your Role

The Clinical Quality team is responsible for reviewing and abstracting medical records to capture data and to ensure accuracy and completeness. The Clinical Quality Reviewer – Nurse Senior will report to the Manager, Clinical Quality Analytics. In this role you will be reviewing medical records to support HEDIS and other regulatory audits. This role will require the ability to train others on HEDIS specifications and guidelines. This role will research and create medical record review reports and interpret findings.

Your Work

In this role, you will:

• Analyze quality issues from both internal and external sources.
• Determinate case level of severity and escalate issues to a medical advisor (MD) and/or credentialing committee for final determination.
• Prepare cases for presentation at physician committees for group review of cases at a higher severity. 
• Prepare corrective action requests for cases in which it is deemed necessary for the provider to institute a change in their present practices including cases where member did not receive necessary treatment or treatment received was potentially harmful. 
• Correspond with physicians regarding corrective actions reviewed while maintaining HIPPA Standards
• Reviewing medical records and documents to abstract clinical data for HEDIS and other audits while identifying opportunities for process improvements
• Meeting daily abstraction and overread goals while maintaining a high accuracy percentage 
• Training and advising healthcare professionals and contingent staff on HEDIS and other audit regulatory compliance
• Support collection of medical record and reports

Your Knowledge and Experience

• Bachelor of Science in Nursing or advanced degree preferred

• ​Current California RN license is required.​ 

• Requires at least 5 years of prior relevant experience. 

• ​Required 3 years of previous HEDIS Medical record review experience

• Excellent analytical and problem-solving skills. 

• ​Requires deep knowledge of job area typically obtained through advanced education combined with experience.   

• ​Viewed as a specialist within discipline. May have broad knowledge of project management. 

• Required experience in Excel and HEDIS audits
• Desired experience and knowledge of medical record systems and processes 
• Desired knowledge and familiarity in EMR software such as Epic, EClinical Works, Allscripts, NextGen, etc.
• Desired knowledge of ICD-10, CPT, and other modifier codes