Job Description

Position Overview:

The primary function of the Clinical Quality Reviewer - Seasonal is to conduct audit of medical charts for compliance with HEDIS, QARR, Medicare Advantage Star measure specifications. This position will be an integral part of the annual Medical Record Review project required to report HEDIS/QARR measures to the NYS Department of Health and Centers for Medicare & Medicaid Services (CMS). The role is seasonal and will be needed from November of the measurement year through May of the reporting year, approximately seven months.

The position may require travel within the five boroughs.

Scope of Role & Responsibilities:

• Maintain knowledge of medical record review and EMR systems.
• Maintain up-to-date knowledge of HEDIS, QARR and Star specifications
• Distribute requests for records and schedules appointments with provider offices to ensure timely completion of duties to meet internal and regulatory standards and requirements.
• Perform clinical audits via EMR, in-house paper medical records, on-site provider visits to collect documentation of measure compliance.
• Data enter accurate and timely findings in the appropriate system(s) in accordance with established documentation standards for MetroPlus Health Plan to ensure integrity of member services provided over the continuum of care and over time.
• Required Education, Training & Professional Experience: Clinical background: Health Educator, LPN, RN, LMSW or LCSW with a minimum of two years HEDIS review experience.
• Experience with medical record review working on HEDIS/QARR in a managed care or health plan setting.
• Proficient in Microsoft Office applications including Word, Excel, PowerPoint and Access

Licensure and/or Certification Required:

Clinical background: Health Educator, LPN, RN, LMSW or LCSW with a minimum of two years HEDIS review experience

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