HEDIS Quality Improvement Nurse

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🔥 1 minute ago

☕ Washington – Remote

☕ Washington – Remote

💵 $80.9k - $125.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Community Health Plan of Washington

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1992

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Community Health Plan of Washington is a nonprofit health plan founded in 1992 by Washington’s community health centers that provides Medicaid (Apple Health), Medicare Advantage, Dual-eligible, and Individual & Family insurance plans across Washington state. It offers care management, behavioral health, virtual care, member support and community services, and programs such as rewards, language assistance, and provider networks to serve members and community health needs.

📋 Description

• Perform medical record review audits and analysis for NCQA and CMS audits • Assist the Manager with developing provider audit reports and provider education • Identify opportunities for process improvement • Perform overread and peer review of other team member output • Update and maintain CHPW HEDIS medical record review and coding guidelines • Interpret changes to NCQA HEDIS Technical Specifications and Medicare Part C & D Star Technical Notes • Support modifying CHPW policies in coordination with HEDIS Performance Measurement and HEDIS Program Managers • Keep current on regulatory, medical record documentation, and coding issues and best practices • Present findings through verbal and written updates to internal audiences, department leadership, providers, clinical teams, and vendor support teams • Update and distribute provider feedback reports to identify provider performance trends • Participate in creating materials for significant audit findings and recommendations • Serve as medical record review and coding subject matter expert • Support overread and validation of colleagues’ documentation performance • Complete annual regulatory HEDIS medical record review and coding quality assurance processes and workflows • Identify and implement quality assurance process improvements • Monitor and comply with internal guidelines, department policies, and NCQA/CMS quality program requirements • Maintain knowledge of Medicare, Medicaid, and Exchange programs • Support chart audit processes for provider and vendor documentation and coding • Act as liaison between internal departments on regulatory data validation audits • Perform root cause analysis for medical record documentation and coding issues • Perform internal and external coding quality reviews • Perform other duties as assigned • Work in an office environment with extended periods of sitting, computer use, talking, and occasional standing

🎯 Requirements

• Licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) • Minimum of five (5) years combined experience performing NCQA, HEDIS and CMS Medicare Star measure medical record and coding review and conducting documentation and coding • Experience with Microsoft Office Suite (Word, Excel, Outlook, and Internet Explorer) and Adobe Acrobat • Comfort with pivot tables at a minimum • Experience with SharePoint, Confluence, and Smartsheet is advantageous • Bachelor’s degree in nursing or an equivalent combination of education and highly relevant experience preferred • Knowledge and experience with NLP, computer assisted medical record review and coding applications preferred • Applied understanding of reimbursement-based CMS Medicare Stars and State Value Base program experience preferred • Knowledge of acceptable medical record and coding standards and criteria in the context of NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes • Strong written and verbal communication • Strong organizational, time management, and prioritization skills • Ability to design and update provider feedback reports • Strong analytical skills and ability to interpret, evaluate, and formulate action plans based upon data • Successful completion of a criminal background check • Must not be sanctioned or excluded from participation in federal or state healthcare programs • Vaccination requirement, subject to medical or religious exemptions • Ability to perform essential functions with reasonable accommodation

🏖️ Benefits

• 10% annual incentive target based on company, department, and individual performance goals • Medical, Prescription, Dental, and Vision • Telehealth app • Flexible Spending Accounts • Health Savings Accounts • Basic Life AD&D • Short and Long-Term Disability • Voluntary Life, Critical Care, and Long-Term Care Insurance • 401(k) Retirement and generous employer match • Employee Assistance Program and Mental Fitness app • Financial Coaching • Identity Theft Protection • PTO accrual starting at 17 days per year • 40 hours Community Service volunteer time • 10 standard holidays • 2 floating holidays • Compassion time off • Jury duty pay • Reasonable accommodation process for disabilities • Medical or religious vaccination exemptions