HEDIS Medical Record Reviewer - Remote (AZ)
Awarded the Best Place to Work 2021, 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.
The remote work opportunity requires residency, and work to be performed within the State of Arizona.
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.
Required Work Experience
- 3 years of HEDIS annual event medical record review experience
- 1 year of Over-read responsibilities
- 2 years of leading or supervising the HEDIS MRR process
- 5 years of experience in a Managed Care environment
- 2 years within a quality management or performance improvement department/team
- High-School Diploma or GED in general field of study
- Active, current and unrestricted license in Arizona (a state in the United States) as a Registered Nurse; or required certification.
- Certified Coder is acceptable in lieu of having a current Registered Nurse licence, as described above.
Preferred Work Experience
- Advanced level experience with all aspects of NCQA’s HEDIS Compliance audit processes.
- Experience creating and deploying NCQA’s Medicare-related MRR training materials.
- Experience with Project Management in a quality management/performance improvement team/department
- Bachelor's degree in business, public health, nursing, or related area
Certified Professional in Healthcare Quality
ESSENTIAL job functions AND 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 Over-read 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.
Required Job Skills
- Familiarity with a variety of software applications and/or vendor tools that are used to manage and/or conduct HEDIS project
- Strong organizational and planning skills, including budgeting in an efficient and productive manner.
- Strong written and verbal communications
- Working knowledge of NCQA’s HEDIS Compliance Audit process, including the MRR Validation component.
- Proficiency with Microsoft office suite applications (Outlook, Excel, Word, PowerPoint)
- Analytical knowledge and skills to evaluate and make decisions based on available information
Required Professional Competencies
- Ability to conform to all established policies, procedures and regulations in maintaining confidentiality and privacy
- Ability to use available information to focus project’s scope and identify priorities.
- Ability to work with business unit managers in a partnership setting.
- Effective presentation skills
- Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
- Independent and sound judgment with good problem-solving skills
- Establish and maintain working relationships in a collaborative team environment
Required Leadership Experience and Competencies
Preferred Job Skills
Preferred Professional Competencies
Preferred Leadership Experience and Competencies
Comply with BCBSAZ corporate and departmental policies and procedures, including, but not limited to Code Blue, Compliance, HIPAA, Computer Responsibility, Accreditation Standards, Attendance, Staff Qualifications, and Quality Management Accountabilities.
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.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.