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  • 18-00105
  • Full Time/Contract
  • Managed Care Nursing
  • Rancho Cucamonga, CA
Job Description
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company To Work For”, "Favorite Training Program”, and "Favorite Workplace Culture” in their 2014 Winning Workplaces survey.

HEDIS Nurse – RN

Under the direction of the Performance Measurement Improvement (PMI) Manager, the HEDIS Improvement Nurse provides support to the PMI Manager and Company departments on HEDIS and Quality improvement related activities, serving as a resource for internal and external customers. This position maintains a working knowledge of the organization's current medical management systems, business processes and workflows in order to support HEDIS and QI-related activities. The HEDIS Improvement Nurse supports compliance of DHCS, CMS, NCQA regulatory requirements related to Quality Improvement Systems, serving as a department SME and project lead.


  1. Responsible for maintaining current knowledge of HEDIS technical specifications with the ability to interpret changes and clarifications accurately to team members across the organization.
  2. Supports outreach and education projects related to HEDIS and other quality improvement initiatives.
  3. Acts as a liaison between the QI/HEDIS department and other departments, practitioners and providers in support of HEDIS related programs and activities.
  4. Provides HEDIS trainings to Company departments and Providers in support of Company's Quality Programs and goals.
  5. Reviews and performs quality assurance reviews of supplemental data medical records, in support of Company's audit standards and requirements for HEDIS reporting.
  6. High attention to detail is required for all medical record abstractions. This is key in ensuring Company is compliant with the high quality standards set for HEDIS medical record audits.
  7. Participates in medical record abstraction and accuracy validations (overreads) for various HEDIS efforts, such as the annual hybrid pursuit, prospective chart reviews, other quality improvement project reviews.
  8. Maintains subject matter expert status in HEDIS medical record standards to support other medical record reviewers.
  9. Any other duties as required to ensure Health Plan operations are successful.
  10. Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company's policies and procedures relating to HIPAA compliance


  • RN License Required
  • Bachelor's degree preferred
  • At least one year experience in quality review of medical records is required.
  • Three or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or health care informatics, preferably in an HMO or managed care setting is required

Knowledge/Skills Required:

  • Strong attention to detail.
  • Data entry, word processing, spread sheet (Excel) and comfort using various systems/tools for research and data entry.
  • Ability to handle multiple projects, data input, strong problem solving capability, excellent interpersonal/communication skills.
  • Working knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes preferred.




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