- Full Time/Contract
- Rancho Cucamonga, CA
Position HEDIS Improvement Nurse Description Under the direction of the Performance Measurement Improvement (PMI) Manager, the HEDIS Improvement Nurse provides support to the PMI Manager and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. Is able to interpret clinical data for QI-related studies for medical management. This position maintains a working knowledge of the current medical management system (MedHOK), business processes and workflows. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.
- Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.
- Acts as a liaison between the QI/HEDIS department and other departments, practitioners and providers to ensure basic understanding of HEDIS projects/issues.
- Responsible for participating in the development, research and implementation of HEDIS improvement activities, as directed.
- Trains other departments on HEDIS related measures, as needed.
- Responsible for assisting the PMI Manager with the HEDIS Improvement Committee (HIC) agenda, maintaining the Action Tracking log, writing HIC minutes, monitoring attendance, ensuring follow up activities are addressed by all departments and submitted timely for the next HIC.
- Reviews and performs quality assurance checks of supplemental data files (both manual and digital) throughout the year, ensuring 100% accuracy.
- Participates in medical record abstraction and accuracy validations (overreads) for HEDIS hybrid pursuit, maintaining subject matter expert status to assist other nurse reviewers.
- Maintains tracking system for regulatory changes to ensure QS management is apprised of significant modifications required.
- Responsible for maintaining knowledge of various other data sources utilized by QS to assist with regulatory compliance.
- Maintains a working knowledge of the current medical management system (MedHOK) and how information is stored and retrieved.
- Able to troubleshoot medical management report requests to determine user needs and objectives, working with users to correctly identify criteria.
- Participates in analysis, interpretation, and translation of complex clinical data, issues, trends, and relationships into effective strategies and action plans for medical management.
- Supports and educates the QI/HEDIS Coordinator in CRM activities, HEDIS data entry, and all other applicable HEDIS related activities.
- Possess basic knowledge of Microsoft Access to look up Member data for purposes of verifying clinical services needed or received. This helps ensure timely processing of Oracle CRM tasks.
- Establishes and maintains effective working relationships with others throughout the organization as well as external customers.
- Responsible for managing assigned projects and effectively communicating with PMI Manager if any project deadlines will not be met, well in advance of the project due date.
- Demonstrate a commitment to incorporate LEAN principles into daily work.
- Three or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or health care informatics is required.
- Experience preferably in an HMO or managed care setting.
- High school diploma or GED required.
- Possession of a bachelor's degree from an accredited institution preferred.
- Possession of an active, unrestricted, and unencumbered LVN and Registered Nurse (RN) license issued by the California BRN
- Yes, must have a valid California Driver's License.
- Working knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes preferred.
- Ability to handle multiple projects, data input, strong problem-solving capability. Strong attention to detail.
- Primary and secondary medical chart reviews which support Global Quality P4P Program, including; Supplemental data process, prospective chart collection, and medical record abstraction projects.
- Temps will need to maintain routine monthly chart review volume while permanent nursing team efforts are shifted to support annual HEDIS Production efforts. (Mining for Information)