HEDIS Quality Specialist

1 week ago


Baltimore, Maryland, United States System One Full time
HEDIS Quality Specialist Job Description

System One is seeking a highly skilled HEDIS Quality Specialist to support a leading health insurance customer. As a HEDIS Quality Specialist, you will be responsible for chart retrieval and conducting thorough medical record reviews using proprietary tools and software.

The ideal candidate will have extensive knowledge of HEDIS measures and be able to accurately and promptly abstract medical records for gap closure and other data collection, all while adhering to HIPAA Privacy and Security standards.

Responsibilities include retrieval follow-up and escalating issues as needed. The successful candidate will also be responsible for meeting productivity and quality targets, enhancing measure compliance, and improving rate submissions according to NCQA guidelines and technical specifications.

This is a great opportunity for recent nurse graduates or individuals with clinical experience looking to transition into a quality assurance role.

Key Responsibilities:

  • Retrieve medical records via EMR or fax request, ensuring compliance with all HIPAA and member confidentiality requirements.
  • Call provider offices to request or validate facility and provider addresses, and/or collect medical records for the HEDIS project.
  • Upload records upon receipt.
  • Document all outreach efforts.
  • Maintain productivity level as specified by the QI Department.
  • Conduct Medical Record Abstraction and Research during the Medical Record Review Project.
  • Use various software applications to support HEDIS operations by entering data and/or changing chase status for the identified chase(s).
  • Utilize extensive knowledge of HEDIS measures to facilitate medical record abstraction for gap closure and additional data gathering.
  • Create and research Pends. Maintain productivity level as specified by the QI Department
  • Ensure compliance with all HIPAA and member confidentiality requirements.
  • Perform all other assigned duties.

Requirements:

  • At least two consecutive HEDIS seasons.
  • Two years clinical experience and good understanding of medical terminology.

What We Offer:

System One is an Equal Opportunity Employer. We offer eligible full-time employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.



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