Location: Remote
Qualifications:
Experience: A minimum of 3-5 years of experience working with the NCQA HEDIS program. Including Medical Record Review, audit process and HEDIS Specification. Excellent written/verbal communication skills.
Must be able to speak, read, and write English proficiently. Ability to effectively present information and respond to questions from managers, peers, physicians, members, and the public.
Job Description – HEDIS Analyst
Overview:
This role enhances the HEDIS Supplemental Data process of over-read, audit, and non-standard data entry. The HEDIS Analyst will utilize all available databases and provide data abstraction to support all partners/markets across the nation. The role works with our Senior Manager of Quality Operations as well as our Senior HEDIS Analyst to support gap file validation as well as all non-standard data abstraction and overread. Works closely with the Quality teams across the nation to ensure that the medical charts meet the standards as outlined by HEDIS specifications and will add support of the internal mock audits throughout the year to mitigate risk in the official audit process. This role will also ensure 100% of all gaps closed via our internal systems are reflected in the health plan’s data.
#1 – Supplemental Data, Over-Read and Audits (70%)
· Reviews medical records from provider offices available through p360, preforms data entry into the HEDIS system (Core) and compares the documentation in the medical record to specifications to determine if preventive and diagnostic services have been correctly performed and recorded correctly into the system.
· Preforms overreads on non-standard data entries as assigned.
· Is highly proficient in the CPT codes to use in the HEDIS engine (Core) to close gaps in care.
· Understands all software and functionality. Ability to run additional reports as needed.
· Maintains expertise in the requirements of HEDIS measures and technical Specification.
· Completes medical record review abstraction while maintaining a 98% or higher accuracy rate.
· HEDIS Analysts are required to attend all measure training and all software training.
#2 – Health Plan Gap Report Validation (15%)
· Responsible for working with Senior HEDIS Analyst to facilitate gap report validation after the health plan has supplied the report and it has been loaded into the HEDIS Engine (Core).
· Each gap report is validated by a systematic review of positive and negative numerator events.
· Upon discovering any issue with the loaded gap report, this position is responsible to report the exact issue as well as supplying screenshots of member/measure combinations that are not loaded correctly.
#3 – Health Plan Reconciliation (15%)
· Works with Senior Manager of Ops, health plans and markets to ensure 100% credit for every gap closed.
Utilizes the Health Plan Reconciliation report or other like report, tracks and monitors data to ensure health plan is closing gaps per our internal data.
...
