|Open Positions: 1
Location: Lee’s Summit, MO (200 Building)
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.
Requires two years of recent RN care management experience in a hospital or managed care setting, such as a health insurance environment. Requires at least three years of nursing experience in a clinical setting. Requires current knowledge of clinical standards of care and disease processes. Requires critical thinking skills, effective verbal and written communications skills to consult with physicians and providers, and demonstrated ability to negotiate costs. Requires 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
GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.