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  • 19-00214
  • Direct Placement
  • Nursing
  • El Monte, CA
Job Description

The QCI HEDIS Nurse is responsible for performing medical record review and audit, data extraction and maintaining the HEDIS data and computer systems. This position will provide clinical support, training, development and engagement with QCIT team and other departments and provide physician & member support as needed. The duties and responsibilities will apply to all IPAs managed by Network Medical Management.Provide clinical support for all HEDIS related projects and interventions initiated by the Quality Improvement Department, including medical record abstraction, aimed at improving HEDIS rates.

  1. Oversee HEDIS data collection and abstraction processes, performs clinical and non-clinical chart reviews, abstraction and data entry for HEDIS measures.
  2. Participates in analysis of aggregate results of existing clinical outcome measures; collaborates with clinical leads and informatics resources to develop, monitor and analyze performance measures.
  3. Be the Clinical Team Lead in the development of new HEDIS interventions and corrective action plans for HEDIS measures that fall below goals.
  4. Participating in ongoing discussions concerning data collections, study design, methodology, and data analysis for HEDIS and Star Measure projects.
  5. Support and research for quality improvement program studies; Assuring the integrity of project data, including data extraction, storage, manipulation, processing and analysis.
  6. Assist in planning and implementation of projects to improve delivery of services and quality of care.
  7. Collecting and collating appropriate data for usage in databases and conducting related research.
  8. Coding accurately variables from original information or data and completing statistical analyses as required.
  9. Prepare and implement annual training for Clinical and Non-Clinical staff regarding HEDIS & STAR.
  10. Responsible for the activities of Cross ACO HEDIS measures
  11. Prepare reports, graphs and presentations.
  12. Understand the principles of HIPAA and maintain confidentiality of patient health information.
  13. Understand the principles of HEDIS and STAR measures based on NCQA and CMS standards.
  14. Communicate internally and externally as needed to gather necessary data.
  15. Attend to provider and interdepartmental calls in accordance with exceptional customer service.
  16. Promotes a positive working relationship between NMM, IPA's and health plan.
  17. Attend IPA and health plan meetings as required.
  18. Respond to IPA and health plan questions/inquiries in a timely manner.
  19. Performs duties in professional manner, utilizing time and resources efficiently.
  20. Performs other duties, projects and actions as assigned.


  • Current CA LVN license in good standing. RN preferred.
  • HEDIS abstraction experience preferred.
  • A minimum of one year clinical experience with HEDIS experience is a plus.
  • Must be detail oriented, be able to meet production standards, and initiate new processes for effectiveness.
  • Basic knowledge of data interpretation and data analysis tools and computer systems technology
  • Knowledge of statistical methodologist and techniques
  • Must value operating in a collaborative and cooperative environment.
  • Ability to show initiative good judgement and resourcefulness.
  • Basic knowledge of ICE, Client, DMHC, NCQA, IHA and CMS standards.
  • Excellent written and oral communication skills, as well as strong interpersonal, critical thinking and analytical skills.
  • Excellent organizational, decision-making and multi-tasking skills
  • Excellent presentation, verbal and written communication skills and ability to collaborate with co-workers, senior leadership and other management.
  • Proven ability to prioritized and organize multi-faceted/multiple responsibilities simultaneously in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
  • Must be able to work independently utilizing all resources available while staying within the boundaries of duties.
  • Must possess the ability to educate and train staff members and other departments as needed.
  • Must have a professional demeanor, good work ethic, and be a conscientious problem solver. Must be willing to learn, take personal pride in their work and be accountable.
  • Must demonstrate leadership and have a team-oriented approach. Prior supervisory experience preferred.
  • Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.
  • Must be ethical and possess the ability to remain impartial and objective.
  • Must be able to travel 15% of work time.
  • Proficient with Microsoft Office (Word, Excel, Power Point) and EZCAP.
  • Personal & Professional Qualities
  • Punctuality, Creativity, Self-motivation
  • Professional appearance and conduct.
  • Conceptual and "big picture” understanding
  • Able to function independently under time constraints
  • Willing to learn and develop new responsibilities and skills
  • Good organization, critical thinking and problem-solving skills
  • Must be detail-oriented and able to work autonomously but also as a team member
  • Should have strong communication and customer service skills and respect for confidentiality. 


Additional Information
Full-Time, Benefited
Direct Placement 


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