HEDIS Overreader

HEDIS Overreader

W2 Contract

Salary Range: $95,000 - $122,000 per year

Location: South San Francisco, CA - Hybrid Role

Job Summary:

Under the direct supervision of the Quality Improvement (QI) Clinical Manager, the Quality Improvement HEDIS Nurse Overreader is responsible for monitoring member health outcomes through internal and external data review. This role evaluates the effectiveness of safe care environments, ensures compliance with regulatory requirements, and confirms that members receive care aligned with evidence-based standards.

Duties and Responsibilities:

• Conduct FSRs, MRRs, and PARs using state-approved tools, applying clinical judgment to assess compliance with regulatory requirements. Document and report all findings.
• Issue, monitor, and document Corrective Action Plans (CAPs) as needed.
• Conduct pre-contractual site reviews for potential provider partners.
• Assess and document compliance with Physical Accessibility standards.
• Maintain detailed knowledge of DHCS site review requirements and procedures.
• Coordinate accurate collection, abstraction, overreads, and reporting of HEDIS medical record data.
• Ensure medical record reviews comply with NCQA HEDIS specifications.
• Accurately translate data elements into the appropriate software or database systems.
• Conduct QI medical record reviews.
• Investigate, determine, and follow up on Potential Quality Issues.
• Develop and implement corrective action plans, providing technical assistance to providers as needed.
• Educate providers and staff on QI activities, corrective actions, and compliance with our company, state, federal, and NCQA standards.
• Analyze data and implement improvement strategies to increase compliance with national benchmarks.
• Meet established productivity, quality, and work output goals.
• Perform computer-based statistical analyses using data from claims, lab results, and other sources.
• Create and update process documentation for QI and HEDIS activities.
• Collaborate with practices to integrate electronic medical record data into our systems.
• Support additional Quality Improvement initiatives as assigned.

Requirements and Qualifications:

• Associate Degree in Nursing required.
• Work cooperatively and effectively as part of a team.
• Communicate clearly, both verbally and in writing.
• Adapt to shifting priorities and requirements.
• Evaluate medical records and healthcare data.
• Plan, organize, and lead data collection efforts.
• Analyze and resolve complex problems.
• Present statistical and technical information clearly using appropriate visual aids.
• Interact professionally with providers, physicians, and internal/external staff.
• Maintain strong working relationships across departments.
• Protect the confidentiality of sensitive medical information.
• Exercise sound judgment within the position's scope of authority.
• Prioritize and complete multiple tasks accurately and within deadlines.
• Bachelor's degree in nursing or a related health services field preferred.
• At least two (2+) years of relevant nursing experience in managed care or quality improvement.
• Must have a personal vehicle, a valid driver's license, and proof of insurance meeting state minimums.
• Willingness to travel primarily within San Mateo County.
• HEDIS reporting.
• Managed health care concepts.
• Medicare, Medi-Cal, and related regulatory programs.
• Quality improvement methodologies and tools (preferred).
• Microsoft Office Suite, including Outlook, Word, Excel, and PowerPoint.

Bayside Solutions, Inc. is not able to sponsor any candidates at this time. Additionally, candidates for this position must qualify as a W2 candidate.

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