Nurse/Clinical Medical Review (HEDIS)

Job Description

Job Title: Nurse, Clinical Medical Review

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Location: Columbia, MD (Primarily remote, but hybrid)

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Duration: 6+ Months Contract

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PURPOSE:

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We are seeking a qualified RN or LPN with experience supporting HEDIS reporting and abstraction processes in a payer, health insurance, or HEDIS vendor environment. The ideal candidate will understand NCQA healthcare quality metrics and have a proven ability to accurately abstract, interpret, and document medical record data for HEDIS gap closure.

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This role will support medical record retrieval, abstraction, pend management, overreads, and other key activities throughout the HEDIS project. The position will help enable the team to conduct the HEDIS Hybrid Project in-house.

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Additional support may include Risk Adjustment medical record retrieval, internal audits, and other identified operational needs.

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Required skills and experience:

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3 years of clinical experience and 5 years of HEDIS experience is required for RN’s and LPN’s. In lieu of a degree, candidates (CNA’s) must have 10 years of relevant HEDIS abstraction and/or overread experience in a payer, health insurance, or HEDIS vendor environment.

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Candidates must be detail-oriented, able to work independently, and maintain a high level of accuracy. Required technical skills include proficiency with Microsoft Office, including Excel, Word, PowerPoint, Microsoft Teams, and Outlook. Experience retrieving medical records from EMR platforms such as Epic, eClinicalWorks, Athena, Cerner, Allscripts, and Tebra is essential. HEDIS overread experience with a health plan or HEDIS vendor is preferred

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Nursing license plus bachelor’s degree in Nursing, Associate’s degree in Nursing, or Diploma in Nursing is preferred.

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A nursing license is preferred but not mandatory. Candidates must complete training, pass test, and maintain satisfactory quality scores.