HEDIS Case Manager

: HEDIS Case Manager Department(s): Quality Analytics Reports to: Supervisor, HEDIS (Healthcare Effectiveness Data and Information Set) FLSA status: Non - Exempt Salary Grade: M - $85,000 - $141,086 ***(Temporary Position - End date of 5/1/2024)*** Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Monday, December 4, 2025 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The HEDIS Case Manager is responsible for reviewing and abstracting medical records for the annual Healthcare Effectiveness Data and Information Set (HEDIS) project. The incumbent will review assigned medical records to determine if documentation meets HEDIS measurement specifications set by the National Committee for Quality Assurance (NCQA) and enter all findings into the NCQA certified software daily. In addition, the incumbent will need to meet daily productivity and data entry accuracy goals, participate in medical record collection, request and abstract additional medical records found through the pursuit process. Duties & Responsibilities:

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Conducts medical record review according to the current NCQA HEDIS Technical Specifications.
• Accurately enters all data and findings into the NCQA certified software. All nurse abstractors/over-readers are required to pass inter-rater reliability testing for all hybrid measures at a 5% error threshold.
• Requests medical records as appropriate from practitioner offices, clinics, hospitals and other clinical facilities.
• Identifies and effectively communicates trends found in medical record review to the HEDIS team.
• Attends weekly and ad-hoc meetings and trainings as needed.
• Abides by the Health Insurance Portability and Accountability Act (HIPAA) and associated patient confidentiality requirements.
• Completes other projects and duties as assigned.

Experience & Education:

• High School diploma or equivalent required.
• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required.
• 3 years of nursing experience required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

• Associate degree in Nursing or related field.
• Current, unrestricted Registered Nurse (RN) to practice in the State of California.
• Relevant experience in medical records management or Quality Improvement (QI) experience with the proven ability to read and interpret medical record data for chart audits or abstractions.

Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee must be able to use hands and fingers, especially for typing on the computer and using the mouse. Work environment : Typical office environment with minimal to moderate noise levels and controlled office temperatures. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit jeid-764740427cd87a4ca54142a177bdb2b8