HEDIS Nurse Reviewer

🔥 0 minutes ago

🦞 Maine – Remote

🦞 Maine – Remote

💵 $86.9k - $107.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Martin's Point Health Care

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🛡️ Insurance

📦 Logistics

💼 Consulting

Insurance • Logistics • Consulting

Martin's Point Health Care is a healthcare organization committed to serving its local communities through high-quality primary and specialty care services. The organization places a strong emphasis on creating a positive workplace culture, recognizing employee contributions, and fostering workforce diversity. Martin's Point Health Care offers a range of career opportunities across various departments, from healthcare providers to corporate roles, and supports employee growth through competitive compensation, development programs, and generous perks. Additionally, the company is recognized for its community impact efforts, raising significant funds for community organizations and encouraging employee volunteerism.

📋 Description

• Perform clinical record reviews, data validations, and overreads for accuracy and HEDIS compliance • Develop reports identifying HEDIS care gaps and trends • Work with providers to ensure services are provided and documented according to HEDIS requirements • Analyze patterns, root causes, and opportunities for process and performance improvement • Support Health Plan Quality programs and regulatory reporting for CMS, DHA, NCQA, and other requirements • Prioritize reports according to business and regulatory needs • Coordinate outreach to request, collect, and secure clinical documentation from providers and provider groups • Identify, collect, document, and store HEDIS data according to procedures and technical specifications • Apply clinical judgment to validate diagnoses, procedures, exclusions, and documentation elements • Educate non-clinical staff on HEDIS requirements and clinical data relevance • Collaborate with physicians, office staff, and care teams to obtain medical records and support HEDIS quality initiatives • Provide education on HEDIS measures, documentation standards, and coding opportunities • Facilitate timely gap-closure activities • Maintain NCQA and other training requirements and meet productivity standards • Perform other assigned duties • Demonstrate the organization's mission, vision, and core values

🎯 Requirements

• Bachelor’s degree in nursing required • Active and unrestricted nursing license required • 5+ years of experience in the health care industry, in HEDIS and/or quality improvement • Experience in a managed care health services environment • NCQA and HEDIS experience • Ability to navigate multiple EMR and health plan applications • Intermediate proficiency in Microsoft Word, Excel, and Adobe • High organization and strong attention to detail • Certified Coder certification preferred • Position is not eligible for immigration sponsorship

🏖️ Benefits

• Comprehensive benefits package • Medical insurance • Dental insurance • Vision insurance • Retirement savings with employer contributions • Paid time off • Volunteer time off • Pie day • Other employee benefits • Potential eligibility for additional compensation, including incentive or commission-based programs, where applicable