Job #: 2098
Title: Clinical Reviewer
Purpose of Position:
The primary function of the Clinical Quality Reviewer is to assess and audit medical charts in compliance with HEDIS/QARR, Medicare Advantage Star measure specifications. This position is an integral part of the annual Medical Record Review project required to report HEDIS and QARR measures to the NYS Department of Health and Centers for Medicare & Medicaid Services (CMS). Quality audit findings from this position will contribute to the support and training of physicians on proper coding and medical record documentation practices to support improvement in quality metrics. This is a seasonal role (October of the measurement year through May of the reporting year), approximately seven months.
Travel may be required throughout the 5 boroughs to support on-site record abstraction.
Perform clinical audits via EMR, in-house paper medical records, on-site provider visits to measure compliance with preventive health guidelines and to measure effectiveness of quality improvement initiatives.
Data enter accurate and timely clinical quality findings in the appropriate system(s) in accordance with established documentation standards for to ensure integrity of member services provided over the continuum of care and over time.
Facilitate retrieval of medical record documentation and work with provider group(s) and in-field navigators to retrieve electronic and paper records that supports HEDIS/QARR.
Records findings of patient encounters to include patient identifiers, relevant information and results in database.
Serve as a final reviewer of HEDIS and QARR records
Maintain knowledge of medical record review and EMR systems.
Maintain up-to-date knowledge of HEDIS, QARR and Star specifications
Other duties as assigned by Quality Review Lead or QM Operations Director.
Clinical background: Health Educator, RN, LPN, RN, LMSW or LCSW, Foreign Medical Graduate (FMG) with a minimum of three years relevant work experience.
2 years’ experience with medical record review working on HEDIS/QARR in a managed care or health plan setting strongly preferred.
3-5 years in Quality Improvement in a health care and/or managed care setting strongly preferred.
Ability to travel within the service area.
Knowledge of HEDIS and QARR specifications.
Experience using EMR systems, e.g. EPIC, Quadramed.
Proficient in Microsoft Office applications including Word, Excel, PowerPoint and Access.
Ability to proficiently read and interpret medical records; Ability to measure compliance and identify deficiencies in chart documentation against standards.
Ability to work in a team setting and independently prioritize projects and assignments.