SPECIALIST, HEDIS/ QUALITY REPORTING (REMOTE-CALIFORNIA)

Job Summary

SPECIALIST, HEDIS/ QUALITY REPORTING oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities.

KNOWLEDGE/SKILLS/ABILITIES

Under the direction of the unit or program manager, the Specialist, HEDIS / Quality Reporting supports the annual HEDIS project management by coordinating the identification, collection and abstraction of medical records and other data in collaboration with other HEDIS staff.

Assists the Manager and Supervisor(s) and / or performs the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review.

• Participates in meetings with vendors for the medical record collection process.
• Assists Manager and Supervisor(s) in training.
• Collects medical records and reports from provider offices, loads data into the HEDIS application, and compares the documentation in the medical record to specifications to determine if preventive and diagnostic services have been correctly performed.
• Works with the corporate HEDIS team to monitor accuracy of abstracted records as required by specifications.
• Participates in scheduled meetings with the corporate HEDIS team, vendors and HEDIS auditors.
• Assists the quality improvement staff with physician and member interventions and incentive efforts as needed through review of medical records documentation.
• Provides data collection and report development support for quality improvement studies and performance improvement projects.
• Assists as needed in support of accreditation activities such as NCQA reviews, CAHPS and state audits by reviewing clinical documentation.

JOB QUALIFICATIONS

Required Education

• Bachelor's degree in related field or equivalent experience, OR completion of any of the following programs:
• Registered Nurse (RN) or State Licensed Vocational Nurse (LVN)
• Certified Healthcare Record Reviewer (CHRR)
• Certified Medical Record Reviewer (CMRR)
• Certified Professional Coder (CPC)

Required Experience

• 2 years coding and medical record abstraction experience.
• 1-year managed care experience.
• Basic knowledge of HEDIS and NCQA.
• Preferred Education from AIMRRA
• Preferred field: Clinical Quality, Public Health or Healthcare.

Preferred Experience

• 2 years HEDIS data collection experience.
• Preferred License, Certification, Association
• Registered Nurse (RN) or State Licensed Vocational Nurse (LVN), or
• Registered Health Information Technician (RHIT), or
• Certified Medical Record Technician with training in coding procedures (as required by state/location only)
• Certified Professional Coder (CPC)