HEDIS Quality Improvement Nurse

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

📋 Description

• Conduct audits and analyses of medical records for NCQA and CMS audits.

• Assist the Manager in creating provider audit reports and facilitating provider education.

• Recognize opportunities for enhancing processes.

• Perform overreads and peer reviews of outputs from other team members.

• Update and maintain the CHPW HEDIS medical record review and coding guidelines.

• Interpret updates to NCQA HEDIS Technical Specifications and Medicare Part C & D Star Technical Notes.

• Collaborate in modifying CHPW policies with HEDIS Performance Measurement and HEDIS Program Managers.

• Stay informed on regulations, medical record documentation, coding issues, and best practices.

• Present findings through verbal and written updates to internal audiences, department leadership, providers, clinical teams, and vendor support teams.

• Update and distribute provider feedback reports to highlight trends in provider performance.

• Engage in the creation of materials for significant audit findings and recommendations.

• Act as a subject matter expert in medical record review and coding.

• Support the overread and validation of colleagues’ documentation performance.

• Complete annual regulatory HEDIS medical record review and coding quality assurance processes and workflows.

• Identify and implement improvements in quality assurance processes.

• Monitor and adhere to internal guidelines, departmental policies, and NCQA/CMS quality program requirements.

• Maintain knowledge of Medicare, Medicaid, and Exchange programs.

• Assist with chart audit processes for provider and vendor documentation and coding.

• Serve as a liaison between internal departments during regulatory data validation audits.

• Conduct root cause analyses for issues related to medical record documentation and coding.

• Execute internal and external coding quality reviews.

• Perform additional duties as assigned.

• Work in an office setting, which involves extended periods of sitting, computer use, conversation, and occasional standing.

⛳️ Requirements

• Must be a Licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN).

• A minimum of five (5) years of combined experience in NCQA, HEDIS, and CMS Medicare Star measure medical record and coding reviews, along with documentation and coding.

• Proficient in Microsoft Office Suite (Word, Excel, Outlook, and Internet Explorer) and Adobe Acrobat.

• Must be comfortable with pivot tables at a minimum.

• Experience with SharePoint, Confluence, and Smartsheet is preferred.

• A Bachelor’s degree in nursing or an equivalent combination of education and highly relevant experience is preferred.

• Knowledge and experience with NLP, computer-assisted medical record review, and coding applications are advantageous.

• Applied understanding of reimbursement-based CMS Medicare Stars and State Value-Based program experience is preferred.

• Familiarity with acceptable medical record and coding standards and criteria related to NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes.

• Strong written and verbal communication skills.

• Excellent organizational, time management, and prioritization abilities.

• Capability to design and update provider feedback reports.

• Strong analytical skills with the ability to interpret, evaluate, and develop action plans based on data.

• Successful completion of a criminal background check is required.

• Must not be sanctioned or excluded from participation in federal or state healthcare programs.

• Vaccination requirement applies, subject to medical or religious exemptions.

• Ability to perform essential functions with reasonable accommodations.

🏝️ Benefits

• 10% annual incentive target based on company, department, and individual performance goals.

• Medical, Prescription, Dental, and Vision coverage.

• Access to a Telehealth app.

• Flexible Spending Accounts.

• Health Savings Accounts.

• Basic Life AD&D insurance.

• Short and Long-Term Disability coverage.

• Voluntary Life, Critical Care, and Long-Term Care Insurance options.

• 401(k) Retirement plan with a generous employer match.

• Employee Assistance Program and Mental Fitness app.

• Financial Coaching services.

• Identity Theft Protection.

• PTO accrual starting at 17 days per year.

• 40 hours of Community Service volunteer time.

• 10 standard holidays and 2 floating holidays.

• Compassionate leave.

• Paid jury duty.

• Reasonable accommodation process for disabilities.

• Medical or religious vaccination exemptions are available.