The Quality HEDIS Medical Review Nurse performs medical record reviews, abstract HEDIS data according to the HEDIS Technical Specifications to include over-reads.
The essential functions listed represent the major duties of this role, additional duties may be assigned.

• The reviewer will collaborate with the HEDIS vendor and perform over-read on reviews.
• Perform administrative functions to include: medical record request, faxing, and calls to members and providers as needed.
• Required to track, monitor and report status of records and volume of work
• Collaborate with a vendor to resolve issues
• Complete claim search to identify the service performed, date of service, provider type, and place of service. Research may include multiple systems and reports
• Be familiar with the Medical Record Abstraction Tool, BI Tool, Diamond system, Healthcare Analytics tool, JIVA, SharePoint and vendor systems.
• Document accurately in the vendor's tool and the Medical Record Abstraction Tool
• Maintain productivity
• Handle calls professionally

Job Requirements

• Active Florida Nursing License with two (2) years of related work experience
• Knowledge of medical terminology
• Experience with medical record/quality review experience. HEDIS/Stars preferred
• Experience applying nationally recognized criteria
• Must be proficient in Microsoft Office (Word, Excel, Outlook) as well as Internet research skills
• Excellent computer skills
• Ability to navigate through multiple systems and screens or medical review requests
• Talking and typing simultaneously
• Effective time management skills
• Effective interpersonal and communication skills
• Ability to use electronic medical record and claims systems
• Problem-solving abilities
• Work respectfully, cooperatively, positively, and collaboratively in an interdisciplinary team
• Organizational skills are very important; must be able to work independently to complete tasks with minimal direction.
• Ability to manage, and prioritize work tasks to adhere to deadlines and identified time frames
• Ability to think analytically and make decisions
• Ability to manage a large workload

Preferred

• Disease management and Home Health experience are helpful.

Required Experience

• Active Florida RN License with two (2) years of related work experience
• Must have previous medical record / quality review experience; HEDIS/STARS preferred
• Must be proficient in Microsoft Office (Word, Excel, Outlook, and PowerPoint) as well as Internet research skills
• Ability to communicate clearly verbally and in writing
• Organizational skills are very important; must be able to work independently to complete tasks with minimal direction.