Clinical Medical Review Nurse

Baltimore, MD _ Remote Role ( May required to come onsite when required )

ROLE: The Clinical Medical Review Nurse (an RN with clinical experience) will report to the Clinical Support Supervisor HEDIS and be part of the Quality Team. The main duties include conducting thorough HEDIS overreads in line with NCQA guidelines. Additional tasks involve helping with Medical Record Retrieval for HEDIS and Risk Adjustment, participating in internal audits for Supplemental Data, and supporting other needs within the Quality Department.

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.

HEDIS Medical Review Nurse