Job Description

Position: Nurse, Clinical Medical Review

Location: Baltimore, MD #HYBRID

Duration: 6months #C2H
Rate: $35/hr

Position is primarily remote but will be required to attend a three-four day in-person training at Client's Canton location as well as travel to local Provider offices for onsite Medical Record retrieval as needed.

Job Description :

• The Clinical Medical Review Specialist (a professional with clinical experience) will report to the Clinical Support Supervisor HEDIS and be part of the Quality Team.
• The main duties include chart retrieval, using proprietary tools and software to conduct thorough medical record reviews in line with NCQA specifications, retrieval follow-up, and escalating issues as needed.
• Main duties will be assigned according to experience, knowledge, skills, and abilities.
• This role requires extensive knowledge of HEDIS measures to accurately and expediently abstract medical records, all while adhering to HIPAA Privacy and Security standards.
• Additional tasks involve helping with EMR Medical Record Retrieval for HEDIS, contacting provider offices to request or validate facility and provider contact information and record retrieval preference, and/or requesting medical records for the HEDIS project and supporting other needs within the Quality Department.

ESSENTIAL FUNCTIONS :

10% Call provider offices to request or validate facility/provider contact information specifically for HEDIS medical record retrieval. Document all outreach efforts.

20% Retrieve medical records via EMR that meet HEDIS requirements and ensure compliance with HIPAA. Upload charts to abstraction platform upon receipt.

40% Use extensive knowledge of HEDIS measures to facilitate accurate and efficient data abstraction from charts within the abstraction platform on a daily basis according to HEDIS specifications and company training guidelines.

20% Use various software applications to support HEDIS operations by creating and researching clinical and retrieval pends

10% Other duties as assigned (see 'additional functions' below)

Additional functions assigned according to experience, knowledge, skills, and abilities :

Overreading (may replace the abstraction function) :

• Accurately and efficiently over-read medical record abstractions (as performed by the HEDIS abstraction staff) within the abstraction platform on a daily basis according to HEDIS specifications and company training guidelines.
• Correct errors identified through the over-read process, including a re-review of charts that may contain similar errors.
• Identify and report abstraction errors and provide measure re-education with the abstractor.

Risk Adjustment :

• Medical Record Retrieval for Risk Adjustment, internal Supplemental Data Audit (PSV) and other Quality and HEDIS related tasks in the off-season

Required Skills :

1. Current knowledge of clinical practices related to HEDIS and Medical Record Review
2. Strong organizational skills, ability to prioritize responsibilities with attention to detail and able to be flexible in shifting tasks as needed
3. Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology
4. Must possess excellent verbal and written communication skills.
5. Strong interpersonal skills. Ability to work independently, as well as a member of a team

QUALIFICATIONS :

• Education: Bachelor's degree in nursing, associate's degree in nursing, diploma in nursing
• Registered Health Information Associate/Registered Health Information Technician, or a related field
• Experience: 3 years clinical experience and 5 years HEDIS experience.
• We are seeking a qualified RN/LPN with experience in the payer/health insurance side of HEDIS reporting abstraction processes.
• The ideal candidate will have a robust understanding of healthcare (NCQA) quality metrics and a proven track record of accurate data abstraction and interpretation.
• Prior experience in HEDIS abstraction of medical records for gap closure within the health plan setting or prior experience with a HEDIS vendor (ex. Reveleer, Cotiviti, Inovalon) is essential for this role.
• Applicants must be detail-oriented and able to work independently while maintaining a high level of accuracy.
• Proficient skills and experience using Microsoft Office (Excel, Word, Power Point, etc.), Microsoft Teams and Outlook are required.
• Experience utilizing various EMR platforms including Epic, eClinical Works, Athena, Cerner, All Scripts, and Tebra to retrieve medical records is essential for this role.
• Proven HEDIS overreading experience for a health plan or HEDIS vendor is a bonus.

Thanks & Regards,
--

LAXMAN
Team Lead - Talent Acquisition

KMM Technologies, Inc.

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