What are the responsibilities and job description for the HEDIS Nurse - Now Hiring position at Actalent?
Description:
- The nurse contractors work typically includes requesting records, abstracting/overreading medical records, performing claims research, preparing medical records for the NCQA HEDIS Auditor, etc.
- Abstracts medical record data from practitioner’s files to support annual Healthcare Effectiveness Data and Information Set (HEDIS) reporting for Wellmark’s accredited products
- Conducts medical record reviews to support the annual reporting and responds to inquiries from provider, and their office staff, regarding the HEDIS initiative
- Review and abstract 40-50 medical records per day, based on NCQA and HEDIS technical specifications
- Document information clearly and concisely from patient record to paper document abstraction tool, or into Wellmark’s electronic HEDIS application
- Ensure Health & Care Management and Wellmark are in compliance with HEDIS audit and technical specification standards
- Participate in the training of NCQA (national committee quality assurance) requirements with completion of Inter-Rater Reliability compliance
- Communicate with internal and external stakeholders by making appropriate follow-up phone calls for additional medical information to complete reviews
- Comply with regulatory standards, accreditation standards and internal guidelines
- Remain current and consistent with the standards pertinent to the Quality Management team
- Will work through Wellmark internal systems and Microsoft Office
Skills:
nurse, HEDIS, RN, registered nurse, medical records, insurance, case manager, URAC, NCQA, LPN, licensed practical nurse, certified medical assistant, CMA, medical billing, medical office, utilization management, quality management, Quality management system, Medical record, Rn license, Quality improvement, Managed care, Chart review
Additional Skills & Qualifications:
• Active or Unrestricted RN or LPN License with 4 years of experience. 2 or 4 year college degree with BSN preferred. T
• HEDIS or Medical Record Review direct and applicable work experience.
• Ability to review medical records and technical specifications. Must be able to draw defensible conclusions from available information.
• Excellent analytical, diagnostic problem-solving skills. Strong attention to detail and ability to identify, research, and analyze issue
• Demonstrated success in roles that require strong time management and work-flow management skills. Ability to prioritize work independently.
• Proficiency with Microsoft Office and Microsoft Teams. Technical aptitude to learn new systems quickly. **Experience with electronic charting is important!
• Experience with EMR systems.
Preferred Qualifications:
• Experience in health insurance, health care, managed care, or a related setting. A strong clinical background could also be considered – e.g., hospital medical records, clinical experience or research.
• Prior work in utilization management, quality management/review, accreditation, or related area.
• Knowledge of regulatory standards - e.g. HEDIS, QRS, NCQA, state/federally mandated processes, etc.
• Familiarity with utilization management, quality, accreditation, or related function.
Experience Level:
Entry Level
About Actalent:
Actalent connects passion with purpose. Our scalable talent solutions and services capabilities drive value and results and provide the expertise to help our customers achieve more. Every day, our experts around the globe are making an impact. We’re supporting critical initiatives in engineering and sciences that advance how companies serve the world. Actalent promotes consultant care and engagement through experiences that enable continuous development. Our people are the difference. Actalent is an operating company of Allegis Group, the global leader in talent solutions.
The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
