Seeking a HEDIS Medical Review Nurse - RN for a 100% Remote position. Must be licensed in Florida.

The Clinical Quality Improvement – STARS Reviewer is a member of the Quality Improvement-STARS team and will work with internal and external partners on clinical quality improvement initiatives related to HEDIS-STARS. The role will serve as a subject matter expert on the HEDIS measures and will be responsible for research, obtaining medical records, and the review of medical records according to established guidelines. Participate in various activities of the Quality Improvement HEDIS Stars Program.

Description

• Perform medical record reviews to support improvement and compliance, abstract HEDIS data, to include over-read of reviews, working collaboratively with the internal HEDIS STARs Team and the Quality Team.
  
• Perform administrative functions to include; medical record requests, faxing, and calls to members and providers as needed. Maintain organized, updated reporting of activities with clear documentation.
• Work collaboratively with the STARS Team in the delivery and development of tools and resources needed to provide HEDIS and STARs training and education to the providers. Participate in provider visits to complete record reviews, collect records, and educate on HEDIS STAR measures
• Complete claim research to identify the service performed, dates of service, provider type, and place of service. Research may include multiple systems and reports.
• Participate in the activities of the Quality Improvement HEDIS Stars Program. Work collaboratively with internal and external management and resources (staff and contractors) to optimize the information available for Stars.
  

Requirements

• Active RN license with 4 years of related work experience
• Experience in or working knowledge of HEDIS, Medicare Stars, and Quality Rating Systems
  
• Knowledge of Compliance Standards and regulatory guidelines such as the National Committee for Quality Assurance (NCQA), and the Center for Medicare/Medicaid Services (CMS).
• Internet research skills, intermediate or higher level of Microsoft Office proficiency (Word, Excel, Outlook, and PowerPoint).
• Ability to travel up to 20% including overnight.
• Ability to communicate verbally and in writing clearly and succinctly to a wide audience including Executive Leadership
• Four years of related work experience.
• Health Policy and Health Insurance Industry experience.
• Project Management Experience.