Clinical Quality Reviewer - Nurse, Senior (HEDIS reviewer)

Job Overview The Clinical Quality Team is responsible for reviewing and abstracting medical records to capture data and to ensure accuracy and completeness. The Clinical Quality Reviewer – Nurse, Senior will report to the Manager, Clinical Quality Analytics. This role involves reviewing medical records to support HEDIS and other regulatory audits, training staff on HEDIS specifications and guidelines, and creating medical record review reports. Responsibilities Analyze quality issues from internal and external sources and determine severity. Train internal staff as needed. Participate in regulatory audits. Work with compliance, process improvement, and member/provider satisfaction departments across all product lines; review, research, and respond to customer complaints related to quality of medical care and service, and recommend or implement process improvements. Review medical records and documents to abstract clinical data for HEDIS and other audits while identifying opportunities for process improvements. Meet daily abstraction and overread goals while maintaining a high accuracy percentage. Train and advise healthcare professionals and contingent staff on HEDIS and audit regulatory compliance. Support the collection of medical records and reports. Qualifications Current California RN license. Bachelor of Science in Nursing or an advanced degree preferred. Minimum of 5 years of relevant experience. Experience in HEDIS medical record review required. Experience in Excel and HEDIS audits. Desired: knowledge of medical record systems and processes; familiarity with EMR software such as Epic, EClinical Works, Allscripts, NextGen, etc.; knowledge of ICD-10, CPT, and other modifier codes. Hybrid Virtual Work This role allows employees to work virtually full‑time; however, employees are expected to come to the office based on business need. Physical Requirements Office environment; roles involve part to full‑time schedule in office. Based in physical offices and work from home office/deskwork. Activity level: Sedentary, frequency most of work day. Job Information Job Identification: 20261081 Job Category: Healthcare Services and Operations Posting Date: 2026‑06‑16T21:33:06+00:00 Job Schedule: Full time Locations: Long Beach, CA; El Dorado Hills, CA; Lodi, CA; Oakland, CA; Rancho Cordova, CA; Redding, CA; San Diego, CA; Woodland Hills, CA Pay Range for California: $90,860.00 – $136,290.00 Pay Range for Bay Area: $102,424.00 – $153,636.00 Role can be filled by a candidate requiring sponsorship: Yes Equal Employment Opportunity External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status, disability status or any other classification protected by Federal, State and local laws. #J-18808-Ljbffr Blue Shield of California