The Quality HEDIS Medical Review Nurse performs medical record reviews, abstract HEDIS data according to the HEDIS Technical Specifications to include over-reads.
- 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 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
- Active Florida LPN or RN License with two (2) years of related work experience
- Experience with medical record/quality review experience. HEDIS/Stars
- Must be proficient in Microsoft Office (Word, Excel, Outlook) as well as Internet research skills
Disease management and Home Health experience is helpful.