Clinical Medical Review Nurse

Ampcus, Inc
United States, Maryland, Baltimore
Nov 12, 2024
Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team. Job Title: Clinical Medical Review Nurse Location(s): Baltimore, MD (Hybrid) We are seeking a qualified RN/LPN with experience in HEDIS reporting and overread processes. The ideal candidate will have a robust understanding of healthcare quality metrics and a proven track record of accurate data abstraction and interpretation. Applicants must be detail-oriented and able to work independently while maintaining a high level of accuracy. Prior experience in HEDIS and overread review is essential for this role. Essential Functions: 50% Accurately and efficiently over-read medical record abstractions performed by the HEDIS abstraction staff on a daily basis according to HEDIS specifications and company training guidelines. Complete the over-read process in the Software Application, including comments if errors are found. Correct errors identified through over-read process, including a re-review of charts that may contain similar errors. Identify and report abstraction errors and provide measure re-education with the abstractor. Utilizes various software applications to support HEDIS operations by entering data and / or changing chase status for the identified chase(s). Maintains productivity level as determined by the QI Department. Maintain compliance with all HIPPA and member confidentiality requirements. All other duties as assigned. 25% Medical Record Retrieval, Abstraction and Research during the Medical Record Review Project. 25% Medical Record Retrieval for Risk Adjustment, internal Supplemental Data Audit (PSV) and other Quality and HEDIS related tasks in the off-season Qualifications: Experience: 3 years clinical experience, and 5 years HEDIS and Overread experience. In Lieu of Education - 10 years of recent HEDIS abstractions / overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, Inovalon, Reveleer) Preferred Qualifications: Bachelor's degree in Nursing, Associates Degree in Nursing, Diploma in Nursing At least two consecutive HEDIS seasons with the same company. Knowledge, Skills and Abilities (KSAs): Ability to effectively communicate and provide positive customer service to every internal and external customer - Proficient Strong interpersonal skills. Ability to work independently, as well as a member of a team - Advanced Current knowledge of clinical practices related to HEDIS and Medical Record Review - Advanced Strong organizational skills, ability to prioritize responsibilities with attention to detail. - Proficient Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology - Proficient Must possess excellent verbal and written communication skills - Advanced Licenses/Certifications: RN - Registered Nurse - State Licensure And or Compact State Licensure RN-VA, DC and or MD Upon Hire Req Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, age, protected veterans or individuals with disabilities.