HEDIS Med Record Reviewer - Medicare Advantage
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
Purpose of the Job
This position is responsible for HEDIS Medical Record Review (MRR) initiatives, including the Over-read. The position also coordinates activities to meet contractual and reporting timeframes, and for anticipating needs as related to established policies and procedures.
Essential Functions and Job Responsibilities
• Lead the HEDIS annual event MRR process, including preparing Roadmap for the MRR section, ensuring adequate seasonal staffing, and leading the assignment of abstractions and over-reading to the team.
• Internal Customers include corporate administrators, management team and staff.
• External customers include accreditation and regulatory organizations, peer review organizations, payers, patients, physicians, clinical registries, and databases.
• Serve as point-of-escalation for medical offices who are non-responsive or slow to respond to medical record requests.
• Create and maintain the HEDIS MRR training manual that is compliant with NCQA/HEDIS technical specifications. Ensure training is integrated with Certified HEDIS vendor’s software platforms, products, and tools.
• Train staff on HEDIS MRR processes, including re-training as needed during the annual event.
• Ensure Overread processes are established and communicated, including a plan to deploy corrective action when needed.
• Collaborate with providers, including delegated provider partner entities and provider office quality/performance improvement staff to improve HEDIS/Star metrics and scores.
• Partner with the HEDIS/QI Business analyst at the close of HEDIS annual event to assess MRR process, including responsiveness at the provider/location level to comply with medical record requests. Develop and proposal a post-HEDIS action plan to target opportunities for improvement.
• Educate providers and staff on all aspects of HEDIS medical record review process.
• Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals.
• Interpret and translate policies, procedures, programs and guidelines.
• Assist in the development of QM policies and desktop procedures as it relates to the Medical Record Reviews of HEDIS and non-standard supplemental data initiatives.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Skills / Requirements
Job Reference #: 5532