HEDIS Nurse Reviewer – New England Region

This is a fully remote position, open to applicants in Maine.

📋 Description

• Conducts clinical chart reviews and audits to ensure precision and compliance with HEDIS measures.

• Generates reports to highlight HEDIS care gaps and trends, collaborating closely with providers to ensure that necessary services are rendered and documented in line with HEDIS requirements.

• Aids in the organization of outreach initiatives to request, gather, and secure clinical documentation from individual providers or provider groups as specified by the individual HEDIS measure specifications.

• Works in partnership with health plan departments to pinpoint HEDIS data sources and develop systems for capturing this data in accordance with HEDIS technical specifications, including supplemental databases.

• Engages with data analysts and quality teams to facilitate performance enhancement.

• Records findings and suggests strategies for improving HEDIS measure performance.

• Utilizes clinical expertise to identify and verify data discrepancies.

• Instructs non-clinical staff on HEDIS requirements and the clinical significance of data.

• Communicates with members and clinical providers to efficiently coordinate care, retrieve medical records, and ensure that patients receive preventive and chronic disease management services.

⛳️ Requirements

• Bachelor’s degree in nursing is mandatory.

• A minimum of 5 years of experience in the healthcare sector, specifically in HEDIS and/or quality improvement.

• Experience in a managed care health services setting is essential.

• Familiarity with NCQA and HEDIS is required.

• Must possess an active and unrestricted Nursing license.

🏝️ Benefits

• Comprehensive health care coverage.

• Opportunities for professional development.

• Annual training provided.