Clinical Medical Review Nurse

Cynet Systems • Contract • Baltimore, MD, US • $35 - $40 / hour • 2w ago

Job Description:

Pay Range: $35.57hr - $40.57hr

The Clinical Medical Review Specialist will support the Quality Team by conducting medical record reviews, abstracting data in accordance with HEDIS specifications, and assisting with EMR retrieval and validation tasks.
This role requires extensive knowledge of HEDIS measures, HIPAA compliance, and the ability to work accurately and independently.

Responsibilities:

Call provider offices to request or validate facility/provider contact information for HEDIS medical record retrieval and document outreach efforts.
Retrieve medical records via EMR in compliance with HIPAA and upload charts to the abstraction platform.
Abstract clinical data from medical records according to HEDIS specifications and company training guidelines.
Use software applications to support HEDIS operations, including creating and researching clinical and retrieval pends.
Accurately over-read medical record abstractions, correct errors, and provide measure re-education to abstractors (as applicable).
Support Risk Adjustment, internal Supplemental Data Audit (PSV), and other quality/HEDIS-related tasks during off-season periods.
Perform other duties as assigned.

Requirement/Must Have:

Bachelor’s degree, Associate’s degree, or diploma in Nursing (RN or LPN).
3 years of clinical experience and 5 years of HEDIS experience.
Robust understanding of healthcare quality metrics (NCQA) and HEDIS abstraction processes.
Experience in HEDIS abstraction for gap closure within a health plan or with a HEDIS vendor (e.g., Reveleer, Cotiviti, Inovalon).
Detail-oriented with the ability to work independently while maintaining high accuracy.
Proficient in Microsoft Office (Excel, Word, PowerPoint), Microsoft Teams, and Outlook.
Experience using EMR platforms including Epic, eClinicalWorks, Athena, Cerner, AllScripts, and Tebra.