Clinical Review Specialist

PURPOSE:  HEDIS Medical Review Contractors are responsible for reviewing and over-reading medical records for HEDIS to assure complete and accurate health plan quality reporting.

PRINCIPAL ACCOUNTABILITIES:

 

  • Performs provider/practitioner medical record review and over-read for HEDIS® and HEDIS®-like measures
  • Reviews assigned medical records in order to verify clinical data elements for HEDIS® reporting, e.g., results of laboratory tests, verification of hypertension and the most recent blood pressure reading, prenatal and postpartum care visits, etc.
  • Identifies findings supported by documentation guidelines with high level of accuracy
  • Maintains HIPAA standards and confidentiality of protected health information; reports critical incidents immediately
  • Communicates identification of pursuit leads for additional medical records, if needed, to other members of the team
  • Completes any related data collection efforts and provider outreach, as needed

 

QUALIFICATION REQUIREMENTS:

 

Education/Experience:

  • Minimum 3-year healthcare/health plan experience
  • Clinical degree highly preferred, including, but not limited to: RN, LVN, LPN
  • Previous HEDIS® experience and/or knowledge preferred
  • Solid knowledge of managed care requirements related to clinical quality
  • Research and detail oriented, excellent proof-reading skills
  • Experience working with HEDIS® software (data entry, reporting) preferred

 

Abilities/Skills:

  • Strong ability to read and interpret medical records
  • Demonstrates effective professional verbal and written communication skills; ability to interact with all levels of staff
  • Demonstrates proficiency in Microsoft Office: Outlook, Excel, and Word and similar applications
  • Professional demeanor and good work ethic; must dress in business casual attire
  • Conscientious problem solver, willing to learn, takes personal pride in their work performance/accuracy
  • Demonstrates ability to successfully prioritize and organize a high volume of work to meet deadlines
  • Attends department meetings as needed

 

  • Apply with Adecco

Reference number US_EN_99_027071_410954