What are the responsibilities and job description for the Quality Specialist – HEDIS position at ICONMA?
Responsibilities
- The Quality Specialist - HEDIS (RN/LPN with clinical experience) will report to the Clinical Support Supervisor - HEDIS and be part of the Quality Team.
- Their main duties include chart retrieval and conducting thorough medical record reviews using proprietary tools and software.
- The role requires extensive knowledge of HEDIS measures to accurately and promptly abstract medical records for gap closure and other data collection, all while adhering to HIPAA Privacy and Security standards.
- Responsibilities also include retrieval follow-up and escalating issues as needed.
- Expertise in HEDIS and Quality Measures is used to meet productivity and quality targets, enhance measure compliance, and improve rate submissions according to NCQA guidelines and technical specifications.
- Retrieve medical records via EMR or fax request, ensuring compliance with all HIPAA and member confidentiality requirements.
- Call provider offices to request or validate facility and provider addresses, and/or collect medical records for the HEDIS project.
- Upload records upon receipt.
- Document all outreach efforts.
- Maintain productivity level as specified by the QI Department.
- Conduct Medical Record Abstraction and Research during the Medical Record Review Project.
- Use various software applications to support HEDIS operations by entering data and/or changing chase status for the identified chase(s).
- Utilize extensive knowledge of HEDIS measures to facilitate medical record abstraction for gap closure and additional data gathering.
- Create and research Pends.
- Maintain productivity level as specified by the QI Department Ensure compliance with all HIPAA and member confidentiality requirements.
- Perform all other assigned duties.
- Bachelor's degree in Nursing, Associates Degree in Nursing, Diploma in Nursing.
- 5 years of recent HEDIS abstractions / overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, Inovalon, Reveleer).
- At least two consecutive HEDIS seasons with the same company. 2 years clinical experience and good understanding of medical terminology.
- Ability to effectively communicate and provide positive customer service to every internal and external customer - Proficient.
- Strong interpersonal skills.
- Ability to work independently, as well as a member of a team - Advanced Current knowledge of clinical practices and related medical policies - Proficient.
- Current knowledge of clinical practices related to HEDIS and Medical Record Review - Advanced.
- Strong organizational skills, ability to prioritize responsibilities with attention to detail - Proficient.
- Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology - Proficient.
- Must possess excellent verbal and written communication skills - Advanced.
- The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs.
- Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
- Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
- Health Benefits
- Referral Program
- Excellent growth and advancement opportunities
