JOB SUMMARY

Actively participate in HEDIS projects for the organization as a nurse auditor. Assist team with data analytics to assure accurate and complete quantitative analysis of HEDIS data. Be familiar with and act as a resource for the organization regarding NCQA HEDIS and CMS QHP Measures Technical specifications, including RADV. Collaborates with teams regarding workflow process improvement, document management, and abstraction education as it relates to HEDIS projects. Responsibilities include monitoring, tracking, trending, analyzing, and reporting all data, performance measures, and other required information requested by the Health and Human Services Commission (HHSC), Centers for Medicare and Medicaid Services (CMS), Texas Department of Insurance (TDI), or any other accrediting or regulatory bodies. Monitors data and action plans as they relate to projects/programs overseen by the HEDIS team.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Conduct provider medical record audits, abstraction and over read reviews to ensure accurate CMS payment and to ensure accurate reporting & monitoring of key NCQA standardized performance measurement activities (HEDIS).

Participate in year-round comprehensive medical records analysis and clinical data analysis, including data quality, provider documentation, coding patterns, record retrieval and targeted solutions for HEDIS. Maintain a database for tracking, trending, and reporting HEDIS, including HHS-RADV.

Responsible for facilitating and helping with the implementation of new and existing healthcare HEDIS strategies for improving internal HEDIS monitoring programs Provide educational feedback to providers regarding risk adjustment and quality of care improvement.

Familiarized with HEDIS to develop into being a subject matter expert for risk adjustment (HHS-RADV) and HEDIS measure technical specifications. Participate as SME and maintain exceptional teamwork with both external partners and internal departments.

Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans and other duties as assigned.


MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure: Registered Nurse in the state of Texas, BSN preferred.

Work Experience (Years and Area):

Two years of experience working in a managed care environment with a strong working knowledge of ICD -10 coding. Experience in Marketplace or Medicare Advantage Plan to include experience in Risk Adjustment preferred.

Management Experience (Years and Area): N/A

Software Proficiencies: Microsoft Office (Word, Power Point, Excel. Outlook)