Reczu
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Overview The Clinical Medical Review Specialist (a licensed clinical professional) supports the HEDIS Quality Team in ensuring accurate and timely medical record abstraction and data validation in accordance with NCQA and HIPAA standards. This role involves medical record retrieval, chart abstraction, over-reading, provider communication, and data management using proprietary tools and EMR systems such as Epic, Athena, Cerner, eClinicalWorks, Allscripts, and Tebra. Assignments will be based on the individual’s experience, knowledge, and critical thinking ability. The specialist will play a vital role in supporting annual HEDIS performance cycles, with opportunities to assist in off-season quality projects.
Essential Functions:
Primary (Abstractor) Duties
Contact provider offices to request or confirm contact information for HEDIS record retrieval. Document all outreach efforts promptly and accurately.
20% – Medical Record Retrieval:
Retrieve medical records via EMR systems, ensuring HIPAA-compliant handling. Upload and index charts in the abstraction platform.
(Occasional local travel to provider offices within MD/DC/VA for record collection may be required.)
40% – HEDIS Abstraction:
Conduct accurate, efficient, and independent chart abstraction using HEDIS and NCQA guidelines. Demonstrate high attention to detail and critical thinking during abstraction.
20% – Data and Software Utilization:
Manage multiple clinical and retrieval pends using proprietary tools. Maintain meticulous documentation across all systems.
10% – Additional Responsibilities:
Support internal quality improvement initiatives, data validation tasks, and other assigned duties as required.
Overreading (Based on Skills/Experience)
Perform quality over-reads of HEDIS abstractions to ensure compliance with NCQA guidelines.
Identify, correct, and document abstraction errors.
Provide feedback and re-education to abstractors when needed.
Track, report, and help reduce error trends through process improvement initiatives.
Risk Adjustment / Off-Season Work
Support medical record retrieval for Risk Adjustment and internal supplemental data audits.
Participate in off-season HEDIS and quality improvement projects as assigned by management.
Qualifications:
Education
Required:
Associate’s, Bachelor’s, or Diploma in Nursing.
Licensure:
Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in good standing.
Preferred:
RHIA/RHIT certification or related healthcare quality credential.
Experience
Minimum 3 years of clinical experience (direct patient care).
Minimum 5 years of HEDIS abstraction experience (payer or vendor).
Preferred: At least 2 consecutive years of HEDIS work with the same employer.
If not a nurse: 10+ years of recent HEDIS abstraction/over-read experience required.
Proven expertise in medical record abstraction, NCQA quality metrics, and data interpretation.
Prior experience with HEDIS vendors such as Reveleer, Cotiviti, Inovalon, or similar platforms.
Demonstrated proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, Teams, Outlook).
Advanced computer literacy and strong technical adaptability are mandatory.
Excellent written/verbal communication, organization, and time management skills.
Demonstrated ability to follow complex instructions and standard operating procedures (SOPs) precisely.
Strong critical thinking and problem-solving skills — ability to identify inconsistencies and make evidence-based decisions.
Work Environment & Additional Details
Work Mode: Primarily remote; must be based in the DMV area (MD/DC/VA) for occasional provider visits or in-person meetings.
Training: Mandatory in-person training at Canton, MD, from December 8–11, 2025.
Attendance is required; travel expenses are not reimbursed.
Work Hours: Monday–Friday, 8:00 AM – 5:00 PM EST.
Travel Reimbursement: Only applicable for multi-site provider visits within the same day; not reimbursed for travel from home to a single office or to the Canton site.
Attendance: Strict — no planned time off permitted during the project duration (December 2025 – May 2026).
Contract Duration: December 1, 2025 – May 1, 2026 (HEDIS season).
End of description
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Get AI-powered advice on this job and more exclusive features.
Direct message the job poster from Reczu
Overview The Clinical Medical Review Specialist (a licensed clinical professional) supports the HEDIS Quality Team in ensuring accurate and timely medical record abstraction and data validation in accordance with NCQA and HIPAA standards. This role involves medical record retrieval, chart abstraction, over-reading, provider communication, and data management using proprietary tools and EMR systems such as Epic, Athena, Cerner, eClinicalWorks, Allscripts, and Tebra. Assignments will be based on the individual’s experience, knowledge, and critical thinking ability. The specialist will play a vital role in supporting annual HEDIS performance cycles, with opportunities to assist in off-season quality projects.
Essential Functions:
Primary (Abstractor) Duties
Contact provider offices to request or confirm contact information for HEDIS record retrieval. Document all outreach efforts promptly and accurately.
20% – Medical Record Retrieval:
Retrieve medical records via EMR systems, ensuring HIPAA-compliant handling. Upload and index charts in the abstraction platform.
(Occasional local travel to provider offices within MD/DC/VA for record collection may be required.)
40% – HEDIS Abstraction:
Conduct accurate, efficient, and independent chart abstraction using HEDIS and NCQA guidelines. Demonstrate high attention to detail and critical thinking during abstraction.
20% – Data and Software Utilization:
Manage multiple clinical and retrieval pends using proprietary tools. Maintain meticulous documentation across all systems.
10% – Additional Responsibilities:
Support internal quality improvement initiatives, data validation tasks, and other assigned duties as required.
Overreading (Based on Skills/Experience)
Perform quality over-reads of HEDIS abstractions to ensure compliance with NCQA guidelines.
Identify, correct, and document abstraction errors.
Provide feedback and re-education to abstractors when needed.
Track, report, and help reduce error trends through process improvement initiatives.
Risk Adjustment / Off-Season Work
Support medical record retrieval for Risk Adjustment and internal supplemental data audits.
Participate in off-season HEDIS and quality improvement projects as assigned by management.
Qualifications:
Education
Required:
Associate’s, Bachelor’s, or Diploma in Nursing.
Licensure:
Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in good standing.
Preferred:
RHIA/RHIT certification or related healthcare quality credential.
Experience
Minimum 3 years of clinical experience (direct patient care).
Minimum 5 years of HEDIS abstraction experience (payer or vendor).
Preferred: At least 2 consecutive years of HEDIS work with the same employer.
If not a nurse: 10+ years of recent HEDIS abstraction/over-read experience required.
Proven expertise in medical record abstraction, NCQA quality metrics, and data interpretation.
Prior experience with HEDIS vendors such as Reveleer, Cotiviti, Inovalon, or similar platforms.
Demonstrated proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, Teams, Outlook).
Advanced computer literacy and strong technical adaptability are mandatory.
Excellent written/verbal communication, organization, and time management skills.
Demonstrated ability to follow complex instructions and standard operating procedures (SOPs) precisely.
Strong critical thinking and problem-solving skills — ability to identify inconsistencies and make evidence-based decisions.
Work Environment & Additional Details
Work Mode: Primarily remote; must be based in the DMV area (MD/DC/VA) for occasional provider visits or in-person meetings.
Training: Mandatory in-person training at Canton, MD, from December 8–11, 2025.
Attendance is required; travel expenses are not reimbursed.
Work Hours: Monday–Friday, 8:00 AM – 5:00 PM EST.
Travel Reimbursement: Only applicable for multi-site provider visits within the same day; not reimbursed for travel from home to a single office or to the Canton site.
Attendance: Strict — no planned time off permitted during the project duration (December 2025 – May 2026).
Contract Duration: December 1, 2025 – May 1, 2026 (HEDIS season).
End of description
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