Nurse Case Manager

Description Under the direction of the Quality Programs Director, the Quality Programs LVN Case Manager plays a key role in supporting HEDIS and quality reporting initiatives, ensuring healthcare providers excel in meeting Quality Measures consistent with the CMS Star Rating Program. This role is responsible for ensuring the accuracy, completeness, and compliance of medical record abstraction and data validation processes that impact HEDIS measure performance, regulatory audits, and quality improvement efforts. The Quality Programs LVN Case Manager reviews medical records across various provider EMR systems, Paper charts repositories, and accurately documents findings and ensures adherence to technical specifications. Additional responsibilities include contributing to departmental workflows, supporting annual training, and advancing broader quality initiatives. This position will require strong organization, communication skills, and feedback to achieve maximum CMS Star Ratings every year. Assists with other clerical duties as required. Professional Duties Engages physicians and office staff to facilitate discussions on HEDIS Part C Part D measures. Performs medical record reviews, abstraction and data-entry for HEDIS as part of HEDIS operations to close GAPs in care. Prepares reports and presentations outlining progress findings, and recommendations for management or regulatory bodies. Conducts monthly reviews in a timely manner and in accordance with established guidelines. Tracks compliance issues, trend data, prepares regular reporting to enhance performance related to HEDIS measures, and distributes to providers and internal teams. Stays informed about the HEDIS/STAR rating requirements and applicable annual updates. Prepares, submits, and bill findings to external stakeholders, ensuring adherence to reporting deadlines. Presents a summary of all tracking reports to identify areas of improvement monthly or upon request. Road travel required - 25% (Victor Valley surrounding cities) Performs other related duties as assigned. Qualifications High School Diploma or equivalent and Graduate from an accredited school for Vocational Nurses. Current California LVN license. One year experience with HEDIS/STAR, medical records review. Able to work in a multi-task, high demand environment. Proficiency in Microsoft Office Suite, including Excel, Word, Outlook, and PowerPoint. Proof of valid Drivers License and current Vehicle Insurance This role will be on-site. Physical Demands Type Description Sitting Approximately 70% of day. Standing Approximately > 15% of day. Walking Approximately > 15% of day. Lifting 0 - 20 lbs. (equipment, supplies) approximately >10% of day. Bending Approximately >10% of day. Kneeling Hearing/Visual Acuity Adequate for use with computers, telephone and/or Blackberry. Approximately 50% of day. Computer Highly technical work environment. Must be able to work minimum of 6 hours a day using keyboard, mouse and monitor. Reaching Above head 75 degrees approximately 25% of day. Hand grip dexterity Approximately 40% of day. #J-18808-Ljbffr