The Nurse Consultant with a HEDIS focus is responsible for reviewing medical records for the annual HEDIS project, the HEDIS nurse documents all HEDIS related items on a regular basis. Reviews and integrates medical information from electronic and paper medical records in a timely manner. Participates in medical record collection, requests and abstracts appropriate medical records, assessing for assigned categories as needed. Reviews assigned medical records in order to abstract specified and required clinical data elements for HEDIS reporting. The nurse must participate in HEDIS training and pass medical record review abstraction training. Performs other duties as assigned.
Under the direction of the Care Management Manager and Administrator, supports the annual HEDIS project management by coordinating the identification, collection and abstraction of medical records and other data elements.
Conducts research in GEHA systems in order to locate specific claim information.
Contact providers on an as needed basis to follow up on requested medical records.
Perform ongoing analysis of medical records.
Communicate effectively and professionally with provider offices as they identify opportunities for improvement.
Responsible for meeting and maintaining high quality standards.
Providing clinical quality management and ad-hoc reporting services, as assigned.
Working with the manager, director and other designated staff to identify and share best practices and opportunities for quality improvement.
Participating in HEDIS interventions including member contact to assist with scheduling screenings and overcoming barriers to adherence to HEDIS measures.
Works with data analysts to ensure identified gaps in care are closed.
Participates in meetings with health plan partners and vendors.
Managing invoices from providers for medical record requests.
Requires a Bachelor’s degree, current RN license in good standing in state of residence and must be eligible for licensure in all 50 US states. Additional years of qualifying work experience may be considered in lieu of Bachelor’s degree.
Two years of recent RN care management experience in a hospital or managed care setting, such as a health insurance environment.
Three years of nursing experience in a clinical setting.
Current knowledge of clinical standards of care and disease processes.
Critical thinking skills, effective verbal and written communications skills to consult with physicians and providers, and demonstrated ability to negotiate costs.
Basic computer skills and knowledge of medical information systems.
Candidate is required to disclose all adverse actions imposed by any State Board of Nursing.
One year HEDIS experience
Knowledge of CPT codes and ICD-10 codes and HEDIS Technical Specification requirements related to the HEDIS measures for data extraction
One year Medical Record Review
Proficient in MS Office applications
Additional Salary Information: Full benefits, paid time off (pto), pension plan
Internal Number: R-000103
Government Employees Health Association (GEHA) is one of the largest national health and dental plans serving federal employees, federal retirees and their families. We value our employees, and we encourage their personal and professional growth.
GEHA has five locations in the Kansas City metropolitan area, including the company's corporate headquarters in Lee's Summit, Missouri. All of our offices are easily accessible by major highways from anywhere in the Kansas City metro area. We also employ Account Executives and Care Management professionals in multiple service regions throughout the United States to support the organization's products
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