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Medical Audit Claim Reviewer
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Quality Nurse Reviewer
1 month ago
Job Summary
The Quality Nurse Reviewer has responsibility for ensuring the quality and timeliness of the medical record review process that supports the reporting of HEDIS hybrid measures. The position is responsible for the execution of all aspects of the scheduling, retrieval, and abstraction processes associated with the review of medical records. The Quality Nurse Reviewer is responsible for working independently to retrieve, review, abstract, and enter pertinent medical data required for certain HEDIS measures. The position works closely with management in evaluation, issues identification, and issues resolution. This position will also participate in ongoing HEDIS improvement activities throughout each calendar year.
Key Responsibilities/Duties – what you will be doing
Collaborate with clinical and non-clinical staff on provider scheduling and medical record retrieval. Track and report daily medical record review progress and clinical data abstraction quality to management. Meet established goals and deadlines, report concerns; and work to make modifications and/or identify corrective actions when required to achieve goals.
Abstract clinical information from medical records according to established policies and procedures; enter data into the medical records management system. Conduct medical record reviews either in the offices or off site at providers’ offices, depending on record review requirements
Qualifications – what you need to perform the job
RN or LPN required with current active licensure in Massachusetts without restrictions. BSN preferred
Minimum of 3 years clinical experience required; minimum 2 years quality improvement / HEDIS preferred. Prior experience with medical record review is preferred.
Commitment to Diversity, Equity & Inclusion
Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities.
This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.
Req ID: R8143
