HEDIS Improvement Nurse

Position Summary / Position

Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers.

Is able to interpret clinical data for QI-related studies for medical management. This position maintains a working knowledge of the current medical management system (MedHOK), business processes and workflows.

Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.

Major Functions (Duties and Responsibilities)

1. Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.

2. Acts as a liaison between the QI / HEDIS department and other departments, practitioners, and providers to ensure basic understanding of HEDIS projects / issues.

3. Responsible for participating in the development, research, and implementation of HEDIS improvement activities, as directed.

4. Trains other departments on HEDIS related measures, as needed.

5. Responsible for assisting the PMI Manager with the HEDIS Improvement Committee (HIC) agenda, maintaining the Action Tracking log, writing HIC minutes, monitoring attendance, ensuring follow up activities are addressed by all departments and submitted timely for the next HIC.

6. Reviews and performs quality assurance checks of supplemental data files (both manual and digital) throughout the year, ensuring 100% accuracy.

7. Participates in medical record abstraction and accuracy validations (overreads) for HEDIS hybrid pursuit, maintaining subject matter expert status to assist other nurse reviewers.

8. Maintains tracking system for regulatory changes to ensure QS management is apprised of significant modifications required.

9. Responsible for maintaining knowledge of various other data sources utilized by QS to assist with regulatory compliance.

10. Maintains a working knowledge of the current medical management system (MedHOK) and how information is stored and retrieved.

11. Able to troubleshoot medical management report requests to determine user needs and objectives, working with users to correctly identify criteria.

12. Participates in analysis, interpretation, and translation of complex clinical data, issues, trends, and relationships into effective strategies and action plans for medical management.

13. Supports and educates the QI / HEDIS Coordinator in CRM activities, HEDIS data entry, and all other applicable HEDIS related activities.

14. Possess basic knowledge of Microsoft Access to look up Member data for purposes of verifying clinical services needed or received.

This helps ensure timely processing of Oracle CRM tasks.

15. Establishes and maintains effective working relationships with others throughout the organization as well as external customers.

16. Responsible for managing assigned projects and effectively communicating with PMI Manager if any project deadlines will not be met, well in advance of the project due date.

17. Demonstrate a commitment to incorporate LEAN principles into daily work.

Experience Qualifications

Three (3) or more years of any individual or combined experience in quality assurance, utilization management, case management, and / or health care informatics is required.

Preferred Experience

Experience preferably in an HMO or managed care setting.

Education Qualifications

Associates in Nursing from an accredited institution required.

Preferred Education

Bachelor's in Nursing from an accredited institution preferred.

Professional Certification

Professional Licenses

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN

Drivers License Required

Knowledge Requirement

Working knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes preferred.

Skills Requirement

Data analysis, word processing, spread sheet (Excel) and some database capabilities. Excellent interpersonal / communication skills.

Abilities Requirement

Ability to handle multiple projects, data input, strong problem-solving capability. Strong attention to detail.

Commitment to Team Culture

The Team environment requires a Team Member to participate in the Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls;

reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds.

Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Position is eligible for Hybrid work location upon completing the necessary steps and receiving HR approval. All positions approved for telecommute or hybrid work locations may periodically be required to report to main campus for mandatory in-person meetings or for other business needs as determined by leadership.